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THE PRINCIPLES 



OF 



OBSTETRICS 



A PRACTICAL MANUAL FOR THE 
STUDENT AND GENERAL PRACTITIONER 



BY 

STANLEY PERKINS WARREN, M.D. 

Obstetric Surgeon to the Maine General Hospital 5 Consulting Physician to the Maine 
Eye and Ear Infirmary. 



PROFUSELY ILLUSTRATED 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCIII 



THE LIBRARY OF 
CONGRESS. 

Two Copiw R»c*iv«* 

AUG 4 '903 

4laS$ ft XXe.N». 
COPY B, ' 






Copyright. 1903. 
Bv WILLIAM WOOD AND COMPANY. 



Go 
MY DEAR WIFE 

A Most Indulgent Listener and Partial Critic 



PREFACE. 



This manual has been prepared at the request of the publish- 
ers, who suggested that a concise, practical text-book upon the 
principles of obstetrics, written primarily from the standpoint of 
the student and at the same time covering the ground in such a 
manner as to be of value to the general practitioner, would be 
appreciated by the teachers and students of this country. The 
most conspicuous defect of the present text-books, of which there 
is no lack, upon this subject is their voluminous size, perhaps the 
only fault of several otherwise admirable manuals. 

It has been the endeavor, therefore, to restrict this work to 
the smallest limits compatible with clearness and completeness. 
Everything of the nature of discussion and theory has been omitted, 
the design being to present the essential facts in plain, simple 
form, in order that the undergraduate student may acquire the 
science more in the shape which it will assume when as a physi- 
cian he puts it to practical use. It is hoped that the book, then, 
will possess the additional advantage of becoming a working hand- 
book adapted to the requirements of private practice, where the 
refinements of hospital instrumentation and nursing are conspicu- 
ously absent. It designs to teach that aseptic midwifery is possi- 
ble under the restrictions of the private home, with the simpler 
armamentarium of the obstetrical handbag. 

The author gratefully acknowledges the assistance of Drs. 
James A. Spalding and Richard D. Small, of this city, in critical 
revision of the manuscript, and the generous co-operation of the 
publishers in its illustration and publication. 

Portland, Maine, June, 1903 



CONTENTS. 



PAGE 

Preface, v 



PART I.— PREGNANCY. 

CHAPTER I. 

Anatomy of the Obstetric Pelvis, . .... 3 

The Obstetric Pelvis, ... 3 

The Soft Parts of the Pelvis, . ..... 9 

CHAPTER »1 
Female Sexual Organs — External, ........ 13 

CHAPTER III. 
Female Sexual Organs — Internal, . 17 

PART II.— PHYSIOLOGY OF PREGNANCY. 

CHAPTER I. 

Menstruation, ..,. ..,-»... 29 
Ovulation, ....... . 30 

Conception, ...... ... 32 

CHAPTER 1 1 

Embryology, . 33 

Development of the Fertilized Ovum, 33 

Fetal Membranes and Deeiduse, ....... 36 

CHAPTER III.. 

Placenta 39 

Umbilical Cord, 42 



viii CONTENTS. 

PAGE 

Growth by Month of the Embryo and Foetus, . . . .42 

Fetal Circulation, v 44 



CHAPTER IV. 

Symptoms of Pregnancy, . • . . . . . . . .46 

First Trimester, , 47 

History, ........ c .. 47 

Physical Examination, ........ 49 

Second Trimester 50 

History, 51 

Physical Examination, 53 

Third Trimester, . . . . . . . ... .58 

History, 58 

Physical Examination, 59 

Classification of Symptoms of Pregnancy for each Trimester, . 61 
Classification of Symptoms of Pregnane)'' according to their Re- 
liability, 62 



CHAPTER V. 

I. Irregularities of Pregnane}', ........ 63 

II. Differential Diagnosis of Pregnancy, ...... 67 



PART III.— HYGIENE AND DISEASES OF 
PREGNANCY. 

CHAPTER I. 
Hygiene, . c . . 73 

CHAPTER II. 

Disorders of Pregnane) 7 .76 

Disorders of the Birth Canal, 76 

Diseases of the Gravid Uterus, . . ■ . . , . .76 

Cervical Diseases during Pregnancy, ...... 80 

Diseases of the Vagina during Pregnancy, . . . . .81 

CHAPTER III. 

Digestive System, ........... 83 

Mouth, 83 

The Stomach, 83 



CONTENTS. 



IX 



Intestines, 

Liver, 

Diseases of the Urinary System 

Diseases of the Respiratory System during Pregnancy 
Diseases of the Circulatory System during Pregnancy, 

The Blood in Pregnancy, 

Diseases of the Nervous System during Pregnancy, 

Infectious Diseases during Pregnancy, . 

Acute Infectious Diseases, . 

Skin Diseases during Pregnancy, . . . . 



PAGE 

88 
89 
89 
92 
93 
95 
96 

97 
97 
99 



Abortion, . 
Miscarriage, 
Premature Labor 



CHAPTER IV. 



100 

108 
108 



CHAPTER V. 



Extra-LTterine Pregnancy 



109 



CHAPTER VI. 

Diseases of Foetus and Appendages, ....... 115 

Chorion, Cystic Degeneration of Villi (Vesicular Mole. Hyda- 

tidiform Mole), 115 

Amnion and Liquor Amnii, . . . . . . . .118 

Deciduse, ............ 120 

Placenta, ............ 121 

Umbilical Cord, . . . . • . 122 

Foetus, ............ 122 



PART IV.— MECHANISM OF LABOR 



CHAPTER I. 

The Factors Concerned 127 

I. The Powers, .......... 127 

II. The Passages, . . . . . . . . . . 131 

III. The Passengers, . . . . . . . , .131 

Diameters of the Fetal Head and their Approximate Average 

Length, . . . . - . . . . . . . .134 

Diagnosis of Presentation and Position by Abdominal and Vag- 
inal Examination, . . . . .''"•'. . . . . 140 

Vaginal Signs of the Different Presentations, .... 142 



CONTENTS. 



PART V.— LABOR AND THE PUERPERIUM. 

CHAPTER I. 

PAGE 

Labor: Its Physiology and Preparation, 147 

CHAPTER II. 

Conduct of Normal Labor, . . -153 

First Stage, 153 

Second Stage, 157 

Third Stage, 163 

CHAPTER III. 

The Puerperium, 168 

Physiology, ............ 168 

Changes in the Reproductive System 169 

Management of the Puerperium — the Mother, . . 171 

The Child, .174 



CHAPTER IV. 
Nursing and Substitute Feeding 178 

PART VI.— PATHOLOGY OF LABOR. 

CHAPTER I. 

Irregularities in Mechanism of Labor, 193 

I. The Powers, . . . 193 

II. The Passages 196 

A. Irregularities of the Hard Parts. B. Of the Soft Parts, . 196 

CHAPTER II. 

Deformity of the Pelvis, 204 

Simple Flat Pelvis, 204 

Justo-Major Pelvis, 2c6 

Justo-Minor Pelvis, 2c6 

Generally Flat Contracted Non-Rachitic Pelvis, ... 207 

Rare Forms of Contracted Pelvis 207 

B. Of the Soft Parts ... 214 



CONTENTS. xi 

CHAPTER III. 

PAGE 

Irregularities in Passengers, 218 

CHAPTER IV. 

Irregularities in Fetal Development, ....... 243 

Fetal Malformations, Monstrosities, and Tumors, . . . .251 

Irregularities in Fetal Appendages, 253 



PART VII.— OBSTETRIC OPERATIONS. 

CHAPTER I. 

Induction of Labor 259 

Indications, 259 

Methods, 259 



CHAPTER II. 

Forceps, ............. 263 

General Indications for Forceps, ....... 265 

General Contraindications, ........ 266 



CHAPTER III. 

Version and Csesarean Section, . . . . . . . 275 

Version 275 

Csesareau Section, or Cceliohysterotomy, ..... 279 

Comparison between Csesarean Section, Symphyseotomy, and 

Craniotomy, 281 



CHAPTER IV. 

Symphyseotomy, ........... 285 

Embryotomy, ............ 288 



PART VIII.— ACCIDENTS COMPLICATING LABOR. 

CHAPTER I. 

Placenta Prsevia and Accidental Hemorrhage, ..... 295 
Hemorrhage, ........... 295 



Xll 



CONTEXTS. 



CHAPTER II. 
Post-Partum Hemorrhage from Uterine Inertia, 



PAGE 

. 302 



CHAPTER III. 

Lacerations of the Birth Canal, 



301 



CHAPTER IV. 



Rupture of the Uterus, 

Inversion of the Puerperal Uterus, 



316 
320 



PART IX.— PATHOLOGY OF THE PUERPERIUM. 

CHAPTER I. 



Puerperal Fever, . 

Special Lesions of Puerperal Sepsis, 



325 
329 



CHAPTER II. 



Puerperal Convulsions, 
Eclampsia, . 



335 
335 



CHAPTER III. 

Diseases of Breasts during the Puerperium, 340 

Mastitis, 3-P 

Subinvolution, . . . 34 2 

Acute Infectious Fevers, 343 

Genito-Urinary System, 34° 



CHAPTER IV. 



Pathology of the New-born Child, . 
Asphyxia Neonatorum, . ' ■ . 
Traumatism, .... 

Disease 

Diseases of the Umbilicus, 
Hemorrhages . 



34S 
348 
352 
354 

357 
353 



Index, 



• 359 



PART I. 
PREGNANCY. 



THE 

PRINCIPLES OF OBSTETRICS 



CHAPTER I. 

ANATOMY OF THE OBSTETRIC PELVIS. 

Obstetrics is that department of medicine which relates to 
midwifery. Its design is the guidance of woman and her children 
during pregnancy, delivery, and the puerperium, the foundation 
of its practice being an intimate knowledge of the hard and soft 
parts of the birth canal. The anatomy of the pelvis and sexual 
organs will be therefore first presented, as briefly as the character 
of the subject permits. 

THE OBSTETRIC PELVIS. 

The obstetric pelvis is the bony girdle or incomplete basin at 
the lower end of the body, containing the female sexual organs, 
and through which the product of conception passes. The stu- 
dent will find a dried pelvis of great assistance while committing 
its details to memory. 

The female pelvis differs from the male in being lighter and 
more shallow, the angle of the pubic arch is straighter, the end of 
the coccyx shorter, and most of its projections are less developed. 
In obstetrics it is never considered as a basin, but a canal, and only 
those details of its structure which are applicable to the specific 
purpose need to be mentioned. 

It is constructed of four bones — sacrum, coccyx, and right and 
left innominate bones, the first two forming one-third, and re- 
mainder the other two-thirds, of the bony canal. 

3 



4 THE PRINCIPLES OF OBSTETRICS. 

In the obstetric sense the promontory of the sacrum means 
the angle formed by the structures included in the sacro-lumbar 
articulation : the base of the sacrum, lower surface of the last lum- 
bar vertebra, and cartilage between them. The cavity of the pel- 
vis at this part is heart-shaped, because the promontory juts into 
it, resulting, when beyond a certain limit, in a special class of pelvic 
deformities. The sacro-iliac synchondrosis is the articulation of 
each wing of the sacrum with the opposing surface of the innomi- 




FlG. i.— Articulated Female Pelvis ; Anterior Surface. 

nate. The curve of the sacrum is its smooth inner surface, which 
varies in every pelvis, from a sharp bend in one to a nearly 
straight line in another. 

The coccyx is the end of the spine, and articulates with the 
sacrum by the sacro-coccygeal joint. After middle life its motion 
is restricted by ossification,, making the two bones practically one, 
thus causing difficult labor. 

The innominate has few details of obstetric importance. On its 
inner surface is an irregular curving ridge, linea ilio-pectinea, or 
ilio-pectineal line, which extends from the sacro-iliac synchondrosis 
downward and forward to meet its fellow of the opposite side. It 
is an important obstetric landmark, since it divides the true pelvis 
from the false and is a base-line for measuring the internal pelvic 



AXAT01IY OF THE OBSTETRIC PELVIS. 



5 



diameters. Upon its crest are the anterior and posterior spinous 
processes, which offer points for obtaining the external pelvic 
diameters. Each innominate unites in front with its fellow by the 
symphysis pubis, the space between the rami of the ischia and the 
pubes being the arch of the pubis. The obturator foramen, be- 
tween the ischium and pubis, is smaller and more nearly triangu- 
lar in the female than the male, and in life is filled with the obtu- 
rator membrane. On the lower edge of the innominate are the 




Fig. 



-Articulated Female Pelvis ; False Pelvis and Superior Strait. 



tuberosity and spine of the ischium and the greater and lesser 
sciatic notches, to which important structures are attached. 

The ilio-pectineal line divides the pelvis into two sections. Of 
these, the upper or false pelvis, because its bony rim is incomplete 
in front, is of no especial obstetric importance. The lower sec- 
tion is the true or obstetrical pelvis, because it contains the sexual 
organs and forms the birth canal. The pectineal line and promon- 
tory of the sacrum mark its upper boundary, variously called the 
brim, inlet, or superior strait. "The dried bony pelvis without 
its muscles is a basin without a bottom. The opening where the 
bottom ought to be is the outlet or inferior strait " (King). 

The internal shape of the true pelvis is of great importance in 
the natural performance of childbirth, there being a standard 



6 THE PRINCIPLES OF OBSTETRICS. 

type with individual variations. It is not a symmetrical bony 
cylinder, but a canal whose front wall is much cut away and the 
deficiency supplied by elastic tissues. This inequality in length 
of the walls bends the cavity forward, making its general direction 
crescentic, with a depth of an inch and one-half in front and five 
inches behind. At the apex of the heart-shaped brim is the sym- 
physis pubis, on the sides the pectineal lines, and opposite the sym- 
physis the promontory of the sacrum. In the recesses on each 
side of the latter are sheltered important blood-vessels and nerve 




Fig. 3.— Articulated Female Pelvis ; Inferior Strait and Outlet. 

trunks, the left having in addition the rectum. Projecting into 
the outlet are the spines of the ischia, from which pass upward 
two low ridges that partition off the side of the canal into two 
shallow surfaces, the anterior and posterior inclined planes of the 
pelvis. The posterior is imperfect in the dried pelvis, but com- 
pleted during life by ligaments and muscles which cover and pass 
through the sacro-sciatic foramina. These planes are the chief 
factors in causing the head to rotate forward or backward during 
labor, 



ANATOMY OF THE OBSTETRIC PELVIS. 7 

If pieces of cardboard were fitted across the pelvic canal, their 
surfaces would represent what is meant by the planes of the pel- 
vis, which are imaginary transverse sections of it at any given 
level. The axis of any plane is an imaginary line passing at right 
angles through it, and indicates the degree of its inclination to the 
body and horizon. For instance, when a woman is standing the 
plane of the brim tilts at an angle of about sixty degrees with the 
horizon, and its axis would be represented by a line passing from 
the umbilicus to the coccyx. While any number of these planes 
could be supposed, only three are needed for obstetrical purposes, 
the brim, middle, and outlet, and by taking the diameters of any 
given plane the dimensions of the canal at that point are obtained. 

If the axes of a number of pelvic planes were united from 
above downward, an irregular curving line would result and be the 
axis of the pelvis, or the so-called " curve of Cams." The true 
direction of the pelvic canal follows the curve of the sacrum, 
which varies greatly in different women, as has been said. "The 
direction of the pelvis may be described with approximate accuracy 
as a line parallel with the sacral curve, and equally distant at all 
points from the pelvic walls " (Hirst). 

The size of the birth canal depends upon race, heredity, habits 
of early life, and disease, with also individual differences. It is 
important to know the typical diameters of the pelvic planes in 
order to judge of the capacity of the canal for the passage of the 
child. While the size of the pelvic interior only is essential, the 
diameters of the exterior also assist in arriving at a conclusion. 
As it is impossible to measure accurately the living pelvis, special 
diameters of the dried pelvis are accepted as standards, and allow- 
ance is made for the soft parts in the living subject. The measure- 
ments given by different writers vary according as they are taken 
to the fractions of an inch, but such precision is generally useless 
and in actual practice impossible except for the expert. The 
present measurements are those of the average living Caucasian 
woman, and are approximate only. 

Internal Diameter at the Brim. — i. The anteroposterior 
(diameter conjugata vera, C. V., sacro-pubic, true conjugate), 
from centre of the promontory of the sacrum to the top of the 
symphysis pubis, 4 inches (10.1 cm.). 






s 



THE PRINCIPLES OF OBSTETRICS. 



2. The transverse (diameter transversa, T.), from side to 
side of the widest part, 4 inches (10.1 cm.). 

3. The first oblique (diameter diagonalis dextra, D. D.), from 
right sacro-iliac synchondrosis to left pectineal eminence, 4^ to 
5 inches (1 1.4 to 127 cm.). 

4. The second oblique (diameter diagonalis laeve, D. L.), from 
left sacro-iliac synchondrosis to right pectineal eminence, 4^ to 5 
inches (1 1.4 to 12.7 cm.). 

At the Outlet. — 1. The antero-posterior (coccy -pubic, conju- 
gate), from tip of the coccyx to lower end of the symphysis pubis, 
4j4 to 5 inches (11.4 to 127 cm.). 

2. The transverse (bisischiatic), from one tuberosity of the 
ischium to the other, 4 inches (10.1 cm.). 

In the Cavity. — 1. The antero-posterior, from the centre of the 
symphysis pubis to the centre of the hollow of the sacrum, 5 inches 
(127 cm.). 

2. The transverse, at the same level as the antero-posterior, 5 
inches (127 cm.). 

" The oblique diameters of the cavity and outlet are of little 
importance since their posterior extremities do not rest on fixed 
points " (Jewett). 





ANTERO-POSTERIOR, • 

c. V. 


Oblique, 
D. 


Transverse, 
T. 




Inches. 


Centi- 
metres. 


Inches. 


Centi- 
me Lres. 


Inches. 


Centi- 
metres. 


Brim 


4 

4 I '2-5 

5 


10. 1 

11.4-12.7 

12.7 


4^-5 


n.4-12.7 


4 
4 
5 




Outlet 

Cavity 


IO I 
12.7 



External Diameters. — The external diameters of the pelvis vary 
somewhat according to the thickness of the overlying tissues, but 
have a general relation to the internal diameters, and are of the 
following average length : 

The external conjugate (diameter of Baudelocque), from the 
dimple just below the last lumbar vertebra to a point half an inch 
below the upper edge of the symphysis pubis, y}4 inches (19 cm.). 
In life three and one-half inches must be taken from this to allow 



AXATOMY OF THE OBSTETRIC PELVIS. 



11 



The sacro-iliac synchondrosis is the articulation between the 
sacrum and ilia, strengthened on both sides by firm ligaments. 
The posterior of these are the most important, since they act as 
slings in suspending the sacrum between other portions of the 
pelvis. 

The coccyx is united to the sacrum by a hinge joint, sacro- 




FlG. 



-Muscles of the Female Perineum. (Testut.) 



coccygeal, which is also reinforced by ligaments and in the adult 
has synovial membranes. 

The symphysis pubis is the articulation between the front 
ends of the pubes, supplied with plates of cartilage, thicker in 
front than behind, synovial membrane, and strong internal and ex- 
ternal ligaments. Below it the subpubic ligament forms the up- 
per boundary of the pubic arch, and the triangular ligament braces 
the sides also of the arch together. 

The lumbo-sacral articulation, between the last lumbar verte- 



12 



TILE PRINCIPLES OF OBSTETRICS, 



bra and sacrum, has a peculiar wedge-shaped cartilage placed with 
its base in front, a construction which not only helps in forming 




Fig. 6.— Relation of Pelvis to Trunk (back). 

the promontory but also tilts the sacrum backward upon the 
spinal column. 



CHAPTER II. 

FEMALE SEXUAL ORGANS. 

The female sexual organs and structures are classified into two 
groups, external or copulative, which are principally concerned 
in the act of impregnation, and internal or formative, within 
which the product of conception is developed and from which it 
is born. 

EXTERNAL SEXUAL ORGANS. 

The female external sexual organs and structures are the 
mons veneris, labia majora, labia minora, vestibule, and clitoris; 
they are called also the external genitalia, or pudendum, and, with 
the exception of the mons veneris, the vulva. 

The mons veneris (mont de Venus) is a cushion of fat and 
fibrous tissue in front of the pubes, separated above by a furrow 
from the lower portion of the abdomen, and continuous below 
with each labium majus. It contains many sebaceous and sweat 
glands, and after puberty is covered with hair. 

The labia majora (greater lips) are two long folds extending 
downward from the mons to surround the vaginal opening, and 
uniting in front at the anterior commissure. Each labium decreases 
in size as it passes downward, combining with its mate at the 
posterior commissure, or merging into the tissues in front of the 
anterior edge of the perineum. When the vaginal orifice is put 
upon the stretch, there appears within it in the virgin a crescentic 
fold of delicate skin, the fourchette, and between it and the pos- 
terior commissure is a slight depression, the fossa navicularis. 
The space between the anus and posterior commissure is the ob- 
stetrical perineum, the external surface being integument covered 
with hair, the internal mucous membrane, and between these are- 

13 



14 



THE PRINCIPLES OF OBSTETRICS. 



olar tissue, fat, and involuntary muscular fibre. The round liga- 
ments extend from the uterus through the inguinal canal and 
are lost in the labia majora; the latter are analogous to the 
scrotum. 

The labia minora (nymphae, lesser lips) are double folds of 
integument, which begin just below the anterior commissure, and 




Fig. 7.— Female External Sexual Organs. 



extend downward about an inch and one-half to the middle of the 
labia majora by which they are covered. Their inner surfaces are 
in contact when at rest. Each labium minus divides into two 
leaflets, the upper joining in front to form the prepuce of the clito- 
ris, and the lower coalescing in front to form the frenum of the 
glans. The histological structure is intermediate between skin and 
mucous membrane, with luxurious vascular and nerve supply. The 



FEMALE SEXUAL ORGANS. 



15 



surfaces of the nymphse are without fat, sweat glands, or hair, but 
have many sebaceous glands whose secretion prevents adhesion 
when the inner surfaces are in contact. The labia minora have 
individual differences in size and shape, being developed enor- 
mously in some races, particularly the Hottentot, and exception- 
ally in the Caucasian. 

The clitoris is analogous to the penis and similar to it in struc- 
ture, but without corpus spongiosum or urethra. It is about one 
inch long: and is situated in the middle line below the anterior 
commissure, where it is 
nearly concealed beneath 
the skin, the only part vis- 
ible being the highly sensi- 
tive glans. The clitoris 
has two small erector mus- 
cles, the cavernous bodies 
being erectile like those of 
the penis, many blood-ves- 
sels and nerves, and is the 
chief organ of sexual feel- 
ing in women. 

The vestibule is the 
triangular space bounded 
above by the clitoris, on the 
sides by the labia minora, 
and below by the vaginal 
opening. A little behind 
its centre is the meatus ure- 
thral or urinarius. Lying 

along the sides of the vestibule and just within the nymphae, 
below the clitoris, are two oblong masses of veins, the bulbi ves- 
tibuli, about an inch in length, communicating freely with neigh- 
boring venous plexuses. They correspond to the corpus spongi- 
osum of the male and during sexual excitement become swollen 
and erect. 

The vulvo-vaginal glands (Bartholin's or Duverney's glands) 
are oblong bodies about one-third of an inch in diameter, situated 
on each side of the vaginal entrance and partly covered by the 




Fig. 



Vaginal Gland. (Testut.) 



16 THE PRINCIPLES OF OBSTETRICS. 

bulbs of the vestibule. Each discharges by a long slender duct, 
opening upon the inner side of the nymphae just outside of the 
vaginal entrance. 

Vessels, Nerves, and Lymphatics of the External Sexual Or- 
gans.— The vascular supply of these structures is very abundant, 
and is derived from the internal pudic for the clitoris, superficial 
and deep external pudic for the labia, and superficial and trans- 
verse perineal for the perineum and adjacent parts. 

The veins accompany the arteries and form large plexuses, 
emptying into the internal pudic. " The veins of these plexuses 
are remarkable for their large size, their frequent anastomoses, 
and the number of the valves which they contain " (Gray). 

The lymphatics empty mainly into the superficial inguinal 
nodes. 

The nerves are branches of the superficial perineal, inferior 
pudendal, and pelvic (inferior hypogastric) plexus of the sympa- 
thetic. 



CHAPTER III. 
INTERNAL SEXUAL ORGANS. 

The internal organs and structures are the uterus, the Fallopian 
tubes, and ovaries, including also the vagina and hymen which 
connect them with the external organs. 

The hymen is a fold of mucous membrane partly closing the 
vagina, from which it is derived, and situated just posterior to the 




Crescentic. Fringed. Bilabial. Biperforate. Cribriform. 

Fig. 9.— Varieties of Hymen. (Testut ) 

fourchette. It is usually crescentic in shape with the concavity 
looking upward, sometimes circular or heart-shaped, and may be 
a septum with many small openings (cribriform), or entirely 
closed (imperforate). As the hymen may be absent from birth 
or destroyed by disease and gynecological examinations, its pres- 
ence is no proof of virginity or its absence of unchastity. It is 
usually torn at the first sexual connection, but may persist to 
and delay delivery, the small projections remaining around the 
vaginal entrance after rupture being the carunculae myrtiformes. 
2 17 



18 THE PRINCIPLES OF OBSTETRICS. 

The vagina extends from the vulva to the uterus in nearly a 
straight direction, generally parallel to the axis of the pelvis. It 
is tubular in shape, flattened from before backward, with the ante- 
rior and posterior surfaces naturally in contact, a cross section 
resembling the letter H. The lower extremity is contracted and 
surrounded by a band of muscular fibre, forming the sphincter 
vaginae. The upper extremity, enclosing the neck of the uterus, 
widens out into the vaginal vault or fornix, and the various por- 
tions are called, in accordance with their relations to the cervix, 
the anterior fornix, posterior fornix, and lateral fornices. The 
length in front is about two inches and a half, and behind from 
four to five inches, and after childbirth the canal never returns to 
its original diameter. 

The walls are composed of three structures: externally a 
fibrous sheath, internally mucous membrane, and between these 
a double layer of muscles, the outer being longitudinal and the inner 
circular. Between the mucous membrane and the muscular coats 
is a layer of loose connective tissue filled with large veins and 
considered to be erectile. Extending along the inner surface of 
the mucous membrane is a central ridge, or raphe, from which 
delicate folds cross to each side of the canal, these corrugations 
providing for the extreme distention necessary during childbirth. 
The vagina is lined with squamous epithelia, numerous papillae, 
especially near the outlet, and is without glands except a few at 
the upper portion. 

The vascular and nerve supply is very great, making it highly 
sensitive. The arteries are branches of the uterine, vaginal, vesi- 
cal, and internal pudic. The veins accompany the arteries, having 
many plexuses continuous with those of the vulva, clitoris, and 
uterus, ending in the hypogastrics, but are without valves. The 
vaginal plexus of nerves arises from the lower part of the pelvic 
plexus. 

The female urethra, though not a sexual organ, is of obstetric 
importance, and therefore is described with the vagina. It is a 
very distensible canal, about an inch and one-half long, and naturally 
about one-half in diameter, beginning at the meatus, passing back- 
ward and slightly upward, and ending at the neck of the bladder. 
The calibre is much larger than is that of the male urethra, being 



INTERNAL SEXUAL ORGANS. 



19 



smallest at the entrance and dilating toward the bladder ; its walls 
are formed of three coats : muscular, erectile, and mucous mem- 
brane. Throughout the latter are many tubular glands, two of 
which, larger than the rest and opening upon the floor of the 
urethra on each side of the meatus, are named, from their dis- 




FlG. 



-Sagittal Section of the Lower Part of a Female Trunk, Right Segment. 
(Testut.) 



coverer, Skene's glands. The meatus urethrse, or urinarius, is a 
small prominence with a vertical slit near the posterior border of 
the vestibule. 

The uterus is the organ of gestation, shaped like a pear, with 
its base upward and long axis slightly curved forward. Its aver- 
age external length in the virgin is three inches, its width one 
inch and a half, its thickness an inch, and its weight one ounce ; but 



20 



THE PPIMIPLES OF OBSTETRICS. 



all these dimensions are increased after childbirth and decreased 
after the menopause. 

It is situated near the outlet of the pelvis, with the vagina 
below, the bladder in front, the rectum behind, and the small in- 
testines resting upon it above. 

This position is not a fixed one, but varies at different times 
and within certain limits. A distended bladder pushes the uterus 
backward, a full rectum displaces it forward, and with every act of 
respiration it rises and sinks in the pelvis ; but ordinarily the uter- 
ine axis is at right angles to that of 
the vagina. 

The uterus is divided, anatomi- 
cally, into body and neck ; the first 
is subdivided into the fundus, the 
broad extremity above the Fallopian 
tubes, middle portion, which tapers 
downward to the isthmus, merging 
into the neck, or cervix, whose out- 
let divides transversely into two lips, 
the posterior being the longer. 

The organ is formed of three 
coats: external, middle, and inner. 
The external or serous is derived 
from the peritoneum, which en- 
velops it like the curtains of a tent, 
covering the whole posterior surface 
downward to an inch below the junc- 
tion of the cervix and vagina, but anteriorly only its upper two- 
thirds. The middle or muscular coat forms the mass of the 
uterus, the muscles being arranged in three layers, which in the 
unimpregnated organ cannot be separated. A thin external layer 
is continuous with the muscular fibres of the Fallopian tubes. 
The middle or principal stratum is disposed in longitudinal, cir- 
cular, and spiral directions, and a delicate inner lining surrounds 
the opening of the Fallopian tubes, forming also a sphincter about 
the internal and external os. The neck or cervix is made up large- 
ly of connective tissue with a band of circular fibres at the vaginal 
junction. 




Fig. 



— Relation of Peritoneum to 
Uterus. (Schaefer.) 



INTERNAL SEXUAL ORGANS. 



21 



During pregnancy all these muscles with their vessels and 
nerves are enormously developed. 

The cavity of the uterus is divided into two unequal portions, 
body and neck. The upper, or body, is triangular in shape, each 
angle forming the cornu in which are the openings of the Fallopian 
tube; the inner surfaces are in contact and are furnished with 
three orifices, one for each Fallopian tube and one for the internal 
os, the latter separating the upper cavity from the lower, or cervix. 



TUBAL VESSELS 



ANASTOMOSIS OF 

UTERINE AND 

OVARIAN ARTERIES 



FALLOPIAN 
TUBE 




VAGINAL VENOUS PLEXUS 



UTERINE ARTERY 



SUPERIOR VAGINAL 
ARTERIES 



OS UTERI VAGINA CUT OPEN BEHIND 

FlG. i2.— Vessels of the Uterus and its Appendages (rear view). (Testut.) 



This portion is slightly flattened and oval, its lower opening be- 
ing the external os, or os tincae. 

The third coat is mucous membrane and lines the whole inte- 
rior of the cavity. It is about one-twenty-fifth of an inch thick at 
the fundus, but is much deeper in the central portion, being 
covered in the natural condition with columnar ciliated epithelia, 
and penetrated by numerous tubular glands, arranged at right 
angles to the surface and lined with ciliated epithelia. The 
mucous membrane of the cervix is denser than that of the body, 
is covered with both ciliated and squamous epithelia, and is dis- 
posed on the anterior and posterior surface in ridges, called arbor 
vitae, or palmae plicatae, which during gestation are obliterated. 



22 THE PRINCIPLES OF OBSTETRICS. 

Ligaments of the Uterus. — The uterus is suspended in the pel- 
vis by three pairs of ligaments: the broad or lateral, one on each 
side, formed by two wide folds of peritoneum, which, after cover- 
ing the uterus anteriorly and posteriorly as has been described, 
unite at its sides, and after enveloping the Fallopian tubes and 
other structures pass to the lateral walls of the pelvic brim ; the 
utero-sacral (post-uterine, folds of Douglas), composed of two 
folds of peritoneum passing from the back and upper portion of 
the vagina to the posterior pelvis, enclosing at its deepest part a 
space called Douglas' cul de sac; and round, partly serous and 
partly muscular, extending from each upper angle of the uterus 
through the inner abdominal ring and inguinal canal, to disappear 
in the mons veneris and labia majora. 

Vessels and Nerves of the Uterus. — The vascular and nervous 
supply is very great, corresponding in growth during pregnancy 
with that of other related structures. Its arteries are remark- 
able for their twisted course and frequent anastomoses, the chief 
supply being the uterine, a branch of the internal iliac, which 
joins the ovarian, derived from the aorta, at the fundus. It 
courses along the side of the uterus, anastomosing freely with 
corresponding vessels from the other side, the largest of which is 
the circular at the isthmus. The veins collect into many sinuses 
that unite laterally in the utero-vaginal plexus, the latter joining 
a mass of veins, called pampiniform plexus, near the ovary. The 
lymphatics are also numerous, ending in the inguinal and lumbar 
nodes. The nerves are chiefly from the sympathetic system. 

Fallopian Tubes. — The Fallopian tube (oviduct, salpinx) is 
the canal between either ovary and the interior of the uterus. Each 
is from three to five inches long, extending from a cornu of the 
uterus along the upper edge of the broad ligament outward to the 
brim of the pelvis, thence inward to the free border of the ovary. 
At the uterine orifice the canal is very small, admitting only a 
bristle ; it dilates widely in the middle portion, or ampulla, and ends 
in a trumpet-shaped collection of projections, or fimbriae, the 
largest being attached to the ovary and the remainder floating in 
the peritoneal cavity into which they open. Each tube has three 
coats : the outer or serous, continuous with the peritoneum of the 
broad ligament ; the middle or muscular, derived from the uterus 



IXTERXAL SEXUAL ORGANS. 



23 



and formed in two layers (the outer longitudinal, enclosing a cir- 
cular) ; and the inner or mucous membrane, continuous with 




Fig. 13.— Cross Section through Isthmus of Fallopian Tube during Pregnancy, illus- 
trating the Folding of the Interior. (Microscopic.) (Schaeffer.) 

that of the uterus, and arranged in many long folds (plicated), 
lined with ciliated epithelia propelling toward the uterus. 

Ovaries. — The ovaries are the female reproductive organs, ana- 
logous to the testes in the male, and are two in number, each lying 
on the side of the uterus, a little below its fundus, in the posterior 
fold of the broad ligament, beneath the Fallopian tube. Their size 
varies with their functional activity, but ordinarily it is that of an 
almond, an inch and one-half long, three-quarters of an inch wide, 
one-half an inch in thickness, and weight one drachm. The pos- 
terior border is convex and free ; the anterior is straight and con- 
tains the hilum. In youth the external surface is smooth ; after 
puberty it is uneven from projecting Graafian follicles and scars 
resulting from their rupture ; in old age it is hard and pale. The 
ovary is covered with a layer of peritoneum supplied with columnar 
epithelia ; below this a thick coat of fibrous tissue, forming the 
tunica albuginea and enclosing the firm ovarian stroma, composed 1 
of fibrous and muscular tissue traversed by numerous blood-vessels.. 
Within the stroma are many small vesicles, the Graafian follicles, 
in all stages of development. 



24 



THE PRINCIPLES OF OBSTETRICS. 



The ovarian ligament extends from each angle of the uterus 
to the inner edge of the ovary. The arteries are the ovarian from 
the aorta at the hilum. The veins accompany the arteries and 
form near the ovary the pampiniform plexus. The nerves are 
from the pelvic (inferior hypogastric) plexus and ovarian plexus, 
and lymphatics are the same as those of the uterus. 




Fig. 14.— Section of Ovary. 



Mammary Glands. — The mammae, or breasts, while strictly 
not sexual organs, are usually associated with them in description. 
These are glandular structures belonging to both sexes, re- 
maining undeveloped, with possible exceptions, during the life 
of the male. In the female they are associated in growth with 
the other sexual organs at puberty, are functionally active after 
childbirth, and atrophy in old age. They are usually two in num- 
ber, situated on the sides of the thorax between the third and 
fifth ribs, with personal differences in size, but either or both may 



INTERNAL SEXUAL ORGANS. 



25 



be congenitally absent. As they are considered to be modified 
sebaceous glands, occasionally there are rudimentary additional 
lobes in anomalous posi- 
tions, the most common of 
these being the axilla. 

Their shape is well 
known. On the surface a 
little below and outside of 
the centre is the projection 
of the nipple resting upon 
the areola, a circle of dark- 
ened skin within which are 
numerous sebaceous glands, 
called Montgomery's folli- 
cles. Internally the breast 
is composed of fibrous and 
fatty tissue, enclosing some 
fifteen or twenty groups of 
glands, or lobes, each pro- 
vided with its own series 
of secreting cells or acini. 
These discharge by minute FlG 
tubes into a single canal, or 
galactophorous duct, for each lobe, all converging in the nipple. 
Each duct widens at its middle portion into the ampulla, or 
reservoir for storing the milk until needed, and contracts to its 
original size at the outlet. 

The mammae are freely supplied with vessels, nerves, and 
lymphatics. 




15.— Right Breast in Sagittal Section, Inner 
Surface of Outer Segment. (Testut ) 



PART II. 
PHYSIOLOGYOF PREGNANCY 



CHAPTER I. 

MENSTRUATION, OVULATION, AND CON- 
CEPTION. 

MENSTRUATION. 

Menstruation (the menses, catamenia) is a periodic hemorrhage 
from the female genitals, called by the laity the "period," 
"monthly turns," "sickness," or "flow.''' The function is analo- 
gous to the rut or heat in lower animals, in which, as well as in the 
human species, scientific explanation for it is still wanting. The 
periodicity is recognized in the word itself, "menstruation" being 
derived from the Latin word mcnsis, a month, because it recurs 
at definite intervals of twenty-eight days. There are personal 
exceptions to this rule, the period occurring in some women a 
few days sooner, in others later than that of the average. 

The composition of the discharge is largely blood from the 
uterus and Fallopian tubes, mixed with mucus from the vagina 
and uterine glands ; it is alkaline in reaction, has a peculiar odor, 
is dark in color, and ordinarily continues about four days. The 
amount varies from four to eight ounces, depending upon the in- 
dividual, and is commonly measured by the number of napkins 
required. The function is usually preceded and accompanied by 
some degree of general discomfort, backache, increasing nervous- 
ness, with swelling of the breasts, and sometimes by a rise of bodily 
temperature — a condition designated as the menstrual molimina. 
The flow may exceptionally be from some other than the sexual 
organs, (the nose, stomach, etc.), and then is distinguished as 
vicarious menstruation ; or if preternaturally early, as in babies a 
few days old, precocious menstruation, and finally may continue 
beyond its natural limits, even after sixty. 

Puberty. — The period of life at which the menses begin varies 
with race, climate, heredity, and social environment, but is gener- 

29 



30 THE PRINCIPLES OF OBSTETRICS. 

ally between thirteen and fifteen. The girl then changes into the 
woman, becoming sexually mature, and assuming the physical and 
mental characteristics of womanhood. 

Menopause. — The habit of menstruation continues from thirty 
to thirty-five years, the flow becoming more scanty during the final 
twelve or eighteen months and ceasing altogether between the 
ages of forty-five and fifty. There are usually accompanying 
nervous disturbances, neuralgias, attacks of indigestion, "hot 
flashes," and other well-known irregularities. 

OVULATION. 

The ovary at birth contains thousands of ova, or nucleated 
germ cells, derived from its epithelial surface, which during child- 
hood lie inactive within the interior of the ovarian structure. But 
at puberty, under the action of certain vital principles of which 
little is known, a few ova take on special changes, ripening like 
fruit upon a tree, the process being called ovulation. There has 
been much study by physiologists upon the question whether 
menstruation and ovulation are coincident in time or related as 
cause and effect. Such clinical facts as that pregnancy has 
occurred before the establishment of menstruation, and that dur- 
ing it and lactation menstruation usually ceases, would seem to 
prove their independence ; but other facts, however, warrant the 
belief that both processes may occur together, resulting from a 
common stimulation from the sympathetic system. 

Inside the ovary are small cavities, the immature Graafian fol- 
licles, enclosing primordial ova, at this time microscopic in size, 
about one one-hundred-and-twentieth of an inch in diameter at 
maturity. From these thousands of ova it is estimated that only 
some three or four hundred are ever developed, so that an im- 
mense number must disappear at their original site. 

The structure of the human ovum resembles that of the com- 
mon hen's egg. It is provided with an outer envelope, zona pel- 
lucida, or zona radiata (possibly also an inner, vitelline membrane), 
containing a granular fluid in which floats near the surface the 
nucleus, germinal vesicle, enclosing the nucleolus about one three- 
thousandth of an inch in diameter. 



MENSTRUATION, OVULATION, AND CONCEPTION 31 

The details of the ovum from circumference to centre are: 
(i) Zona radiata, (2) vitelline membrane, (3) yolk, (4) nucleus 
or germinal vesicle, (5) nucleolus or germinal spot. 

The home of the ovum is the Graafian follicle, whose wall has 
two layers (tunica fibrosa and tunica propria), enclosing a clear 
fluid (liquor folliculi) provided with a special membrane (membrana 
granulosa), one of whose cells develops more than the others, 
becoming the true ovum or germ cell. It assumes a place at the 
edge of the cavity of the follicle where a mass of the granular 
matter gathers about it, forming the discus proligerus. 

The details of the Graafian follicle are: (1) Tunica fibrosa, 
(2) tunica propria, (3) membrana granulosa, enclosing the (4) pro- 
ligerous disc, (5) central fluid. 

When the follicle is about to ripen, its central fluid increases 
rapidly, the ovarian tissue over it thins away, and it appears now 
as a reddish knob, the size of a pea, upon the surface of the ovary. 
The fluid increases until its pressure bursts the sac walls, and 
their contents, the ovum and nest of granular matter, are washed 
out into the peritoneal cavity. 

Either just before escaping from the follicle or after entering 
the peritoneal cavity the now fully developed ovum undergoes the 
change called maturation, by which it is fitted for impregnation. 
Its nucleus approaches the circumference of the ovum, where two 
small rounded bodies form (polar globules), which disappear soon 
after. Later the nucleus returns to the centre of the ovum, re- 
ceiving a new name, the female pronucleus. Impregnation is 
the union of the male pronucleus, the head of the spermatozoon, 
with the female pronucleus. 

Corpus Luteum.— Certain retrograde changes occur in the 
Graafian follicle after its rupture and the discharge of the proliger- 
ous disc. The capsule thickens by growth of connective tissue and 
fills with blood, from the twelfth day -wrinkling into folds and 
modifying in color from red to yellow. The new formation then 
decreases in size until, after thirty days, nothing remains except 
a small pit or scar upon the surface of the ovary — the false corpus 
luteum, or yellow body of menstruation. 

If the ovum from a Graafian follicle should become impreg- 
nated, its corpus luteum also develops, forming the corpus luteum 



32 THE PRINCIPLES OF OBSTETRICS. 

vera, or true yellow body of pregnancy, which is simply the false 
corpus exaggerated. The size increases for thirty or forty days 
after conception, when it fills perhaps a third of the entire ovary, 
reaching full development at the fourth month of gestation, after 
which time it gradually fades away and a month later is a smaller 
fibrous nodule. The true corpus luteum belongs to the ovary 
from which the impregnated ovum came, but occasionally is 
found in that of the virgin. 

CONCEPTION. 

Conception or impregnation is the fertilization of the mature 
ovum by the male germ cell, the spermatozoon. It should be 
understood that the process has never been observed in the 
human species or other of the mammalia, but only in certain 
invertebrates and vegetables, in whom it is considered to be 
analogous to that in the higher orders. 

The spermatozoa are peculiar epithelial cells secreted by the 
testes, microscopic in size, from one-six hundredth to one-four 
hundredth of an inch long, composed of a flattened head and long 
hair-like tail, the cilium. Each floats in the fluid derived from 
the male genital organs, moving about by the vibratile action of 
the cilium at an estimated rate of an inch in seven or eight min- 
utes. It may live for several days in the alkaline fluids of the 
female sexual canal, dying under the action of heat and cold, acids, 
and other germicides, and when dried. 

Impregnation is the passage into the ovum of usually a single 
spermatozoon through the vitelline membrane, taking place ordi- 
narily at the fundus of the uterus, but also at any point of the 
Fallopian tubes, ovary, or peritoneal cavity." The head of the 
spermatozoon (the male pronucleus), enters the female pronucleus, 
after which the cilium disappears, the fertilized egg receiving the 
name of oosperm. Conception takes place at the time of this 
union, and may happen at any time of the menstrual month, but 
is most probable during the first eight days after the end of men- 
struation. 



CHAPTER II. 

EMBRYOLOGY. 

DEVELOPMENT OF THE FERTILIZED OVUM. 

As has been stated in the preceding chapter, the fully matured 
ovum is a simple cell with an outer envelope, zona radiata or vitel- 
line membrane, surrounding the vitellus or yolk in which float 
the nucleus and its central spot, the nucleolus. After impregna- 
tion the immediate changes are in the nucleus, which begins a 




Fig. 16. — Segmentation of the Ovum. (After van Beneden.) 



process of division or segmentation, always occurring in multiples 
of two. Thus the original ovum separates into two other nucleated 
cells (blastomeres), these into four, the four into eight, etc., the 
final mass arranging itself into a thin layer enclosing a central 
group (morula or muriform body). The segmented cells differ in 
size and appearance, the larger being called epiblast or ectoderm, 
the smaller hypoblast, entoblast, or entoderm. These collect 
around the circumference of the ovum, the epiblast enclosing the 
3 33 



34 



THE PBIXCTPLES OF OBSTETRICS. 



hypoblast except at one point (blastophore), that soon closes and 
disappears, a cavity forming which early fills with liquid. A little 
later these layers separate, between them appearing a third layer 




FIG. 17.— Section View of Ovum, after Segmentation. (After van Beneden ) 

(mesoblast), the whole now being called the blastodermic vesicle 
or blastula. 

Upon one side of the blastoderm an oval cloudy spot develops 
(area germinativa, or embryonic spot), in whose middle a clear line 




Fig. 



■Blastodermic Vesicle. (After van Beneden.) 



makes its appearance (area pellucida), within which the cells con- 
dense into a long rod (the primitive streak), or initial structure of 
the primitive embryo. Still later on two folds of the mesoblast 
rise on either side of the primitive streak, like hills on each side 
of a valley, afterward dividing into two layers with spaces between, 



EMBRYOLOGY. 35 

that finally develop into the body cavity or ccelom. The outer of 
the two layers of the mesoblast unites with the epiblast to form 
the somatopleure, or primitive body wall ; the inner with the hypo- 
blast to form the splanchnopleure, or rudimentary digestive tract. 
The following arrangement of these structures will help to 
keep them in mind : 

„ r Male pronucleus. ) ^ 

Ovum J f - Fertilized ovum. 

( Female pronucleus. ) 

, Blastomeres. \ 
Segmented nucleus. •] Morula. j- Blastula, blastodermic vesicle. 

( Fluid. ) 

^Epiblast. |- Somatopleure. 

Blastula J Mesoblast. \ ^er ayer. 

1 ( Inner layer. i i u i 

{ Hypoblast. J Splanchnopleure. 

Blastoderm develops : Embryonal layer, 



Primitive streak, 
Primitive groove. 

Recent investigation would seem to warrant the following 
arrangement of organs derived from these membranes : 

Epiblast (ectoderm, external blastodermic membrane) forms 
the epidermis and its appendages (hair and nails), its glands in- 
cluding the mammary, nervous system (brain, spinal cord, ganglia, 
and nerves), and organs of special sense. 

Mesoblast (mesoderm, middle blastodermic membrane) forms 
the muscles and skeleton (bones, cartilages, ligaments, connective 
tissues), heart, blood-vessels, blood glands, spleen, lymphatics, the 
genito-urinary system, and reproductive organs. 

Hypoblast (entoderm, entoblast, internal blastodermic mem- 
brane) forms the epithelial lining of the digestive canal and its 
glands, and epithelial lining of the lungs and air passages (King). 

The above statement of the development of the embryo is, of 
course, the merest outline of a most intricate process. Much of 
the detail of embryology is still being investigated, and can be 
better understood by reference to the extensive works upon that 
subject. 

Umbilical Vesicle and Vitelline Duct. — The three layers of 



36 THE PRINCIPLES OF OBSTETRICS. 

membrane — epiblast, mesoblast, and hypoblast — become narrowed 
at a point near the caudal extremity of the embryo, forming two 
cavities of unequal size. The smaller (inside the embryo) develops 
into the abdominal cavity, the larger (outside) becomes the yolk 
sac or umbilical vesicle, the canal between them forming the vitel- 
line duct, through which the yolk is absorbed by the embryo. 
This entire formation exists only in very early fetal life, growing 
smaller as the yolk is taken up by the embryo, and finally disap- 
pears in the sheath of the umbilical cord. 

FCETAL MEMBRANES AND DECIDUjE. 

Fetal Membranes. — The fetal membranes form the sac wall 
within which the foetus lives until birth, and are called the amnion, 
allantois, chorion, and decidua reflexa. 

Amnion. — The anmion is derived from folds of the somato- 
pleure, which spread out within the circumference of the ovum, 
surrounding the embryo and forming a sac with double walls. The 
outer layer (false amnion) unites with the vitelline membrane, mak- 
ing a single layer (subzonal membrane). The inner (true amnion) 
is the immediate envelope for the foetus, and when fully developed 
furnishes a cover for the fetal surface of the placenta. Its 
physiological function is to provide a nutritive and protective fluid 
for the foetus. 

The liquor amnii is an alkaline secretion from both mother 
and foetus, with a specific gravity of from 1.005 to 1.008, at first 
clear and limpid, afterward changing to any shade of color, brown 
or green, from admixture with waste epithelia and sebaceous 
matter from the skin of the foetus, and meconium from its intes- 
tines. It keeps the child warm, protecting it from external injury 
(blows, falls, etc.), and probably supplying it with a small amount 
of nourishment. The latter is demonstrated by the fact that 
lanugo and epidermal scales are sometimes found in the fetal stom- 
ach, into which they must have been swallowed with the liquor 
amnii. 

AllantO-S. — Between the layers of the amnion are developed 
two temporary structures, designed to furnish nourishment for 
the embryo — the umbilical vesicle, previously described, and allan- 



EMBRYOLOGY. 37 

tois. The latter is largely composed of blood-vessels for the use 
of the future placenta, forming from the extremity of the mucous 
membrane of the intestine, and spreading out inside the layers of 
the amnion until at about the third week it fills its cavity. The 
stalk of the allantois outside the abdominal cavity of the embryo 
assists in forming the umbilical cord, and the portion within the 
cavity dilates into the urinary bladder and urachus, the latter after 
birth changing into the suspensory ligament of the bladder. 

Chorion. — About fourteen days after impregnation, delicate 
projections or villi appear upon the surface of the vitelline mem- 




Fig. 19.- Diagram of Gravid Uterus, showing Formation of Decidual and Placenta 

(Testut.) 

brane, attaching it to the uterine decidua and drawing nourishment 
from it. The modified membrane is now called the primitive 
chorion, to distinguish it from a later and more important structure. 
Very early after the formation of the allantois its middle sub- 
stance is absorbed, the inner and outer layers coalescing and unit- 
ing with the interior of the false amnion. The resulting envelope 
is then compounded of the vitelline membrane, two layers of 
allantois, and false amnion, and called the chorion. Its uterine 
surface immediately begins to grow shaggy with luxuriant club- 



38 THE PRINCIPLES OF OBSTETRICS. 

shaped villi, containing blood-vessels from the allantois, the ovum 
at this time resembling a flattened chestnut burr, or a " little bunch 
of whitish gelatinous moss." About the third month two-thirds 
of the chorionic villi atrophy, leaving a smooth surface (chorion 
laeve), the remainder growing profusely (chorion frondosum), and 
completing their development in the placenta. 

Deciduae. — Under the stimulus of menstruation the mucous 
membrane of the uterus hypertrophies, its glands enlarge, and 
blood-vessels multiply. If now an ovum becomes impregnated, 
extra stimulus is given to the growth of the membrane until it 
nearly fills the uterine cavity, receiving the name of decidua vera 
or uterine decidua. 

Whatever the point in the Fallopian tube or uterus at which 
the ovum may be impregnated, in natural gestation it fastens itself 
to some part of the mucous membrane of the latter, usually near 
one of the cornu, now wrinkled under the pressure of menstrua- 
tion into folds, two of which grow around it, forming the decidua 
reflexa, or ovular decidua. 

The portion of decidua vera to which the impregnated ovum 
is attached receives a special name, decidua serotina or placental 
decidua, because it is the region at which the placenta will after- 
ward develop. 

These structures will be more readily understood if it be 
remembered that the decidua vera is simply ordinary uterine 
mucous membrane modified by pregnancy, the decidua serotina 
that part of the decidua vera upon which the ovum is attached, 
and the decidua reflexa the folds of decidua vera surrounding it. 

At this stage of growth the embryo has three envelopes: 
inside nearest to it amnion, next chorion, and outside decidua 
reflexa. As development continues the first two lose their iden- 
tity, merging into a single sac wall, which by the fourth month 
has expanded with liquor amnii enough to fill the whole uterine 
cavity and line the entire decidua. The decidua reflexa disappears 
completely after the seventh month, and the remainder of the sac 
is expelled with the placenta after labor. 



CHAPTER III. 

PLACENTA AND UMBILICAL CORD. 

PLACENTA. 

The placenta, by the laity ordinarily called •'afterbirth," or 
"the cake," is a fetal organ, whose function ends with the birth of 
the child, and is then discarded with the amniotic membranes. 

As has been described at a certain stage in the development of 
the chorion, the larger part of its villi atrophy, while the remainder 
pass on to a higher organization. At the point of contact between 
the chorion and decidua serotina their respective villi, now multi- 
plied in size and number like the terminal branches of a tree in 
spring-time, sustain the most intimate relations, much like that 
when the leaves of a book are pushed between those of an- 
other. These hypertrophied chorionic villi are the source of the 
placenta. 

Its initial structure appears about the second month of gesta- 
tion, maturing in a few weeks more, and may be described as a 
tangle of frail blood-vessels enclosed in a delicate network of 
connective tissue. At term it has grown to a soft fleshy mass, 
round and flattened, seven or eight inches across, one inch thick 
in the centre or at the spot where the cord is attached, one-third 
to one-half an inch thick at the edges, weighing a little more than 
a pound. The size usually corresponds with that of the child, a 
large child having a large placenta, and vice versa. 

The placental surfaces differ as they are related to the uterus 
or foetus. The inner or fetal side is smooth, covered with the am- 
nion, beneath which vessels traverse about in every direction, in- 
creasing in size from circumference to centre, and uniting at the 
latter into five or six principal arteries and veins, from which are 
derived the three vessels of the cord. The uterine surface is 
widely contrasted with the fetal, and its exact anatomical relation 

39 



40 



THE PRINCIPLES OF OBSTETRICS. 



to the decidua serotina is unknown. Only the briefest abstract 
can be given here of this perplexing subject. 

The placenta is composed of tufts, or cotyledons, packed to- 
gether like small sponges, fifteen or twenty in number, made up 
of masses of chorionic villi, greatly enlarged from their original size 
and each provided with a loop of vessels. These villi shoot for- 
ward between the glands of the uterine mucous membrane, there 
resembling the trunk of a tree with its branches. The capillaries 




Fig. 20.— Fetal Surface of Placenta. 



around the walls of each cavity, into which a fetal villus projects, 
enlarge, form a network about each villus, and later, the inter- 
spaces being absorbed, unite into large sinuses, to which maternal 
blood is carried by minute arteries from the decidua. By this 
anatomical construction, fetal blood circulates within its own sys- 
tem of villi, whose exterior float in the blood of the mother. A 
means of communication between mother and foetus is thus sup- 
plied for interchange of gases (the placenta acting as the fetal 
lung or gill), nutrition, and excretion, allowing fetal absorption of 



BLACEXTA AXB UMBILICAL COBB. 



41 



inorganic matters, such as morphine, strychnine, or the virus of cer- 
tain diseases like variola, but screening out particular micro-organ- 
isms, the tubercle bacillus for instance. The functions of the 
placenta are therefore many : as a respiratory organ, it receives 
oxygen and discharges carbonic acid gas ; as a storehouse of food, 
it provides nourishment ; and as an excretory medium, it carries 
away waste. 

Intervillous circulation is sluggish, and probably due to irregu- 
lar contractions of the uterus. 




Fig 2i.— Maternal Surface of Placenta. 



The normal situation of the placenta is at the upper quadrant 
of the uterine cavity, but may be at any point of the interior, as 
in placenta praevia. Though naturally single, tufts sometimes 
develop at a distance from the main body, which may or may not 
be connected to it, as in placenta succenturiatae, or the entire 
placenta may envelop the ovum, and is then called placenta mem- 
branacea. In multiple pregnancy each foetus may have its own 
placenta, or be supplied in common by a single organ. 



42 THE PRINCIPLES OF OBSTETRICS. 



UMBILICAL CORD. 

The umbilical cord (funis, navel string) is the vascular con- 
nection between foetus and placenta, appearing at first as the 
stalk of the allantois, by which the chorionic villi are pro- 
vided with many blood-vessels, only three of these remaining at 
a later period of growth and continuing as the proper umbilical 
vessels. 

The funis at term averages about twenty inches in length and 
half an inch in diameter, though there are endless variations in 
these dimensions. It has a central gelatinous structure, enclosing 
and protecting two arteries and one vein, the atrophied umbilical 
vesicle and vitelline duct, with a sheath of fibrous tissue derived 
from the epidermis of the foetus. The vein is ordinarily larger 
than the arteries by which it is surrounded, this anatomical 
arrangement giving a tortuous character to the cord, which has 
been aptly compared to a twisted rope of tissues. Both vein and 
arteries are furnished with circular and semicircular valves. The 
blood which circulates through the cord is reversed in character 
from that of similar vessels after birth, since the funic arteries 
carry venous blood, and the vein carries arterial. 

GROWTH BY MONTH OF THE EMBRYO AND F(ETUS. 

In this book the product of conception up to the third 
month of intra-uterine life is called the embryo, afterward the 
foetus. 

First month. The youngest human ova seen and described 
have been from 8 to 13 days old. Thus early the ovum is a flat- 
tened, gray, jelly-like mass, about as large as a pigeon's egg. The 
embryo, in a specimen 28 to 30 days old, was 0.31 5 of an inch long 
and weighed 36 grains. Most of the ovum is filled with the um- 
bilical vesicle. All the internal organs are rudimentary, as are 
also the arms and legs. 

Second month. Ovum size of hen's egg. Embryo one inch 
long. Body straighter. Head and extremities distinct. Eyes, 
ears, and nose visible. Limbs separated into their three divisions, 



PLACENTA AND UMBILICAL CORD. 43 

fingers and toes webbed. Sexual organs evident but not distinct. 
Chorion formed and villi everywhere upon it. 

Third month. Ovum size of goose egg. Embryo 2\ to 3^ 
inches long. Umbilical cord twisted and 1.7 inches long. Fin- 
gers and toes lose the web, and nails indicated. Bone centres in 
nearly all bones. Cavities are closed. Sex distinguished by pres- 
ence or absence of uterus. Placenta, though small, is easily 
distinguished. 

Fourth month. Foetus 4 to 6.75 inches long, weight 3 to 5 or 
6 ounces. The head is a quarter of the whole body, sex plain. 
Lanugo present, and a few hairs on the scalp. The intestines 
contain meconium. The foetus can move its limbs a little and may 
live, if born, for a few hours. 

Fifth month. Foetus averages 8§ inches long, weighs about 9 
ounces, head relatively very large, eyelids begin to open. Heart 
sounds may be heard and quickening takes place. If born may 
try to cry, but lives only a short time. 

Sixth month. Toward end of the month foetus is 10 to 12 
inches long, weighs 1 pound 9 ounces. Umbilical cord midway 
between symphysis pubis and sternum. Testicles still in abdo- 
men. If born may live several days. 

Seventh month. Length 13 to 15 inches, weight 2^ pounds. 
Lanugo everywhere present upon the skin. Meconium in the 
intestine. Pupillary membrane now disappears. May live, but 
generally dies. 

Eighth month. Foetus 15 to 16 inches long, weight 3 J 
pounds. Hair on scalp abundant, lanugo disappearing; left 
testicle usually in scrotum. Nails reach to finger tips. If born 
may live. 

Ninth month. Length 16^ to 17^- inches, weight 4^ pounds. 
Head diameters one-half to two-thirds of an inch less than at 
term. 

Tenth month. Foetus is now mature, averages 15 to 20 inches 
long, weight 7 to *]\ pounds. Intra-uterine motion is vigorous, 
and urine may be passed into amniotic cavity. Heart beats from 
120 to 160 times a minute. Ossification in the lower epiphysis 
of femur, and just beginning in the upper epiphysis of tibia, as- 
tragalus, and cuboid. 



44 



THE PRINCIPLES OF OBSTETRICS. 



FETAL CIRCULATION. 

Since oxygenation of the fetal blood takes place not in the fetal 
lungs but in the placenta, a special arrangement of the circulation 
is necessary. From the placenta the blood passes through the 
umbilical vein, entering the body at the umbilicus, and after sup- 




Liver 



FIG. 22.— Fetal Circulation. (After Preyer.) 

plying a small quantity to the liver, flows through a special canal 
(ductus venosus) into the ascending vena cava. It is now partly 
arterial from the placenta, partly venous from the liver and lower 
extremities, and continues on to the right auricle, where it devi- 
ates from the course taken by all air-breathing animals. Instead 
of passing from the heart to the lungs and back to the left heart, 



PLACENTA AND UMBILICAL COED. 45 

a special route is required in response to the conditions of intra- 
uterine existence. 

The Eustachian valve guides the stream across the right auri- 
cle into the left auricle and ventricle and thence through branches 
of the aorta to the upper extremity, an arrangement explaining 
the relative excess in size of the head over other fetal members. 
Returning by the descending vena cava to the right heart, it passes 
through the pulmonary artery, not, as after birth, to the lungs 
(excepting a small portion for their nourishment), but immediately 
into the aorta by a temporary branch, the ductus arteriosus. From 
the aorta the current supplies the trunk, bifurcating into two 
streams, one of which passes on to the lower extremity. The 
other is driven through two temporary vessels (hypogastric 
arteries), one on each side of the bladder, to the umbilicus, enter- 
ing the cord through the umbilical arteries and returning to its 
starting-point, the placenta. 

The fetal circulation differs from that of the child in these 
respects : 

i. Oxygenation is accomplished through an accessory organ, 
placental rather than pulmonary. 

2. The blood is largely arteriovenous, second hand, in com- 
position. 

3. The short cut through the heart. 

4. The temporary vessels, ductus venosus and ductus arterio- 
sus, to relieve unnecessary hepatic and pulmonary pressure. 



CHAPTER IV. 
SYMPTOMS OF PREGNANCY. 

The question of the existence of pregnancy is one of the most 
important that confronts the physician, upon his answer often 
depending consequences of the greatest interest to himself and 
patient. The laity commonly expect from him an immediate 
confirmation of their suspicions, and error on his part will almost 
surely injure his professional reputation. It is essential, there- 
fore, that he should be familiar with its symptoms and differen- 
tial diagnosis from other abdominal enlargements. 

A positive diagnosis of pregnancy from symptoms alone is im- 
possible in the earlier months, and even up to actual delivery has 
been the cause of many errors by undoubted experts. This is 
not to be wondered at when it is remembered that it has but two 
positive signs, which are not available until the last half of the 
condition. Up to the time of quickening the consensus of symp- 
toms is merely presumptive, and any professional opinion based 
upon them must be largely conservative. 

Several methods of grouping the symptoms are used by 
authors, such as possible, probable, or positive, according to their 
reliability, subjective as derived from the patient, or objective from 
the examination of the practitioner. The most natural plan would 
seem to be, first, to get the history from the woman herself, then 
verify her statements by a thorough physical examination. For 
many reasons, such as ignorance upon the part of the patient, 
fright, desire to deceive herself or others, etc., personal details are 
of little value in establishing the condition, and at their best can 
only confirm the results of the professional inquiry. The latter, 
too, depends upon the time of gestation and the skill of the 
examiner. Diagnosis of pregnancy is sure only when movements 
of the foetus and sounds of its heart are clear and unmistakable. 

The clinical history of the woman under examination for the 

46 



SYMPTOMS OF PEEGXAXCY. 47 

detection of pregnancy is ordinarily the relation of certain mental 
and physical conditions usually associated by the laity with child- 
bearing. To the trained senses of the physician many of these 
are trivial, and few only have practical bearing upon the subject. 
From the results of his physical examination he may be able to 
settle the question at once ; more commonly he is compelled to 
defer judgment until a later period. The suggestion of Hirst is 
timely, that the signs of pregnancy " may be divided into those of 
three trimesters, or periods of three months each. It is useless 
for the practitioner to look for certain signs in one trimester, only 
available in the next." 

FIRST TRIMESTER. 

History. Physical Examination. 

i. Amenorrhoea. I. Changes in size and position 

2. Gastric disturbance. of the uterus. 

3. Mammary symptoms. 2. Softening of the cervix. 

4. Nervous irregularities. 3. Hegar's sign. 

HISTORY. 

1. Amenorrhoea. — A sudden arrest of the menses, without 
rational explanation, between the ages of fifteen and forty-five, is 
strongly presumptive of pregnancy. The unmarried woman 
should have the benefit of the doubt, but amenorrhoea in a healthy 
married woman, who is not nursing, is usually due to conception. 
Of course there are many other grounds for suspension of the 
menses : lactation, disease of the sexual and pelvic organs, unusual 
mental strain, change of climate, sea voyage, exposure to inclem- 
ent weather, etc. Any or all of these possibilities must be con- 
sidered in making a diagnosis, but statements of the individual 
herself as to the presence or absence of the monthly period are 
unreliable, for such reasons as fear of detection in the unmarried, 
self-deception, spurious pregnancy at the menopause, etc. Among 
certain races impregnation often occurs before puberty, and 
women sometimes menstruate for one or two months after con- 
ception, but very exceptionally after the third or fourth, because 
then the cervix is closed by the mucous plug and the uterine cavity 



48 THE PRINCIPLES OF OBSTETRICS. 

filled with decidua. In such irregularities the flow is unusual in 
amount and duration, and in these cases, when looking for an 
explanation of the amenorrhcea, possible causes should not be 
accepted for probable. It is ordinarily safe to believe cessation of 
the menses in a healthy woman, married or single, who is not at 
that time nursing a child, presumptive evidence of gestation, and 
a valuable early symptom. 

2. Gastric Disturbance. — This condition may be entirely ab- 
sent, or when present vary in character with every pregnancy. 
Although sometimes immediately following a fruitful connection, 
it usually appears about the sixth or seventh week continuing to 
the twelfth, or exceptionally even to labor. The amount varies 
from temporary nausea to the most intractable vomiting, " per- 
nicious vomiting," "hyperemesis gravidarum,'' the latter occasion- 
ally not being relieved by its alternative, induction of abortion, 
but going on to a fatal termination. Usually a morning sickness, 
it sometimes recurs with every meal or at any time through the 
day, the husband now and then being affected simultaneously 
with his wife, the latter cases being of course sympathetic only. 
The nausea and vomiting of pregnancy are generally reflex in char- 
acter, from irritation of the stomach due to distention by the 
growing contents of the uterus, but they may be caused by or asso- 
ciated with organic disease of that or other portions of the body. 
Salivation and " cotton spitting " may accompany the nausea. 

3. Mammary Symptoms. — These are valuable for diagnostic 
purposes in first pregnancies only, being of no especial importance 
in multiparas. Soon after impregnation the breasts respond to 
the unusual congestion of the pelvic sexual organs, becoming sen- 
sitive and turgid. If, in addition to these changes, colostrum or 
milk can be expressed from the nipple, gestation is probable. 

4. Nervous Irritability. — Disturbances of the nervous system, 
of every variety and degree, almost always accompany gestation, 
appearing as tendencies to fainting, peculiarities of thought and 
desire, perversions of appetite, "nerve storms/' hysteria, etc., 
which may be temporary or persistent. Pressure of the uterus 
upon the bladder, caused by its descent during the first two 
months, produces irritability of the latter, a frequent accompani- 
ment and suggestive indication of pregnancy. 



SY3IPT02I8 OF PREGNANCY. 49 



PHYSICAL EXAMINATION. 

i. Changes in Size and Position of the Gravid Uterus. — As a 

consequence of increasing size and weight, the gravid uterus 
descends into the pelvis, becoming anteflexed and thereby caus- 
ing irritability of the bladder from pressure. After the fifth or 
sixth week it commences its upward development, and at the 
third month the fundus may be felt at the level of the symphysis. 
Up to this time the length of the uterus is determined by 
examination with some difficulty, but its body appears by palpa- 
tion to be decidedly broader and shorter, the contour changing 
from the unimpregnated pear shape to that of "an old-fashioned 
fat-bellied jug." Descent is accompanied with deepening of the 
umbilicus and, in some women, with flatness of the abdomen. 

2. Softening of the Cervix. — Soon after impregnation the lips 
of the cervix begin to soften, a condition which progresses upward 
until at delivery the entire neck is flexible and dilatable. Goodell's 
suggestion is worth remembering, that the cervix of the unim- 
pregnated uterus is as hard as the tip of the nose, but when 
gravid as soft as the lips. As a result of this softening, the cervi- 
cal canal dilates slowly from below upward until, in primiparae, 
it admits the tip of the finger, and in multiparae the entire finger 
can pass into the uterine cavity. Softening and dilatation of the 
cervix, being merely relative conditions, are suggestive only of 
pregnancy, being found also in disease of the uterus and its 
adnexa. 

3. Hegar's Sign. — From the sixth to the eighth week of preg- 
nancy the uterus on palpation feels very soft at the isthmus, 
contrasting with its ordinary firmness when non-gravid. This sen- 
sation of compressibility is called " Hegar's sign " and is obtained 
in the following manner : place the woman in the lithotomy posi- 
tion, depress the uterus with one hand above the symphysis, insert 
the forefinger of the other deep in the rectum and the thumb into 
the vagina, making pressure upon the intervening uterus just at 
the junction of body and neck. In favorable cases (lean and re- 
laxed abdominal walls), the isthmus feels thin like a piece of card- 
board, or is recognized with difficulty as if there was an actual sepa- 

4 



50 



THE PRINCIPLES OF OBSTETRICS. 



ration here. This sign may be found occasionally by bimanual 
examination, the hand outside pushing down the uterus upon the 
fingers in the vagina, and evident softening is presumptive of 
gestation. 




Fig. 23. — Bimanual Examination for Hegar's Sign. 

For the general practitioner, the most reliable symptoms of 
pregnancy are (1) the characteristic softening of the lips of the 
cervix, and (2) bulging downward of the lower uterine segment. 



SECOND TRIMESTER. 



History. 

1. Gastric disturbance lost. 

2. Mammary changes increased. 

3. Abdominal enlargement. 

4. Quickening. 



Physical Examination. 

1. Fetal heart sounds. 

2. Uterine souffle. 

3. Ballottement. 

4. Funic bruit. 

5. Fetal movements. 

6. Intermittent uterine contrac- 

tions. 

7. Blueness of vulva and vagina 

(Jacquemin's or Chadwick's 
sign). 



SYMPTOMS OF PREGNANCY. 



51 



HISTORY. 

i. Gastric Disturbance Lost — Nausea and vomiting of the 
early weeks of pregnancy usually disappear by the end of the 
fourth month ; the appetite returns, with perceptible increase of 
body weight, restoration of ordinary health, and relief of mental 
anxiety. 

2. Mammary Changes Increased. — During the second three 
months, the changes in the breasts become very evident by uni- 




\ 

Fig. 24.— Primary Areola. 



form growth and firmness, the nipple also enlarging somewhat and 
becoming prominent, while in first pregnancies colostrum can be 
squeezed from it. The areola darkens in color from a little deeper 
flesh color to almost blackness, varying in degree according to 
the complexion of the individual. Within the pigmented area 
develop the so-called follicles of Montgomery, hypertrophied seba- 
ceous glands, ten or twelve in number, often as large as buckshot. 
Between the fifth or sixth month a secondary areola forms around 
the primitive one, appearing as a mottled ring of lighter spots 
than the surface upon which it rests. 



52 



THE PRINCIPLES OF OBSTETRICS. 



These changes in the breasts are valuable signs of first preg- 
nancies only, unreliable in multiparas because often continuing in 
them through successive impregnations, and sometimes accom- 
panying ovarian or uterine disease in the non-pregnant. Taken 
with other symptoms, the above-described mammary changes are 




FIG. 25.— Secondary Areola. 



presumptive but never reliable indications of pregnancy. Sudden 
loss of milk during lactation is highly suggestive of impreg- 
nation. 

3. Abdominal Enlargement. — After the third month the ute- 
rine tumor rises above the pubes, growing upward until at the 
fourth month the fundus is half-way to the umbilicus, reaching it 
at the sixth. The contour is more oval than pear-shaped, with its 
long axis vertical. The abdomen commences to be prominent, 
the flanks widen, and the gait on walking begins to be charac- 
teristic of the condition. These changes in the figure are often 
so gradual that they are easily concealed by tight lacing and ar- 
rangement of the dress, sometimes being overlooked by the wo- 
man herself. 

The umbilicus gradually rises to the level of the skin during 
this trimester. 



SYMPTOMS OF PREGNANCY. 53 

4. Quickening. — Somewhere about the eighteenth week the 
pregnant woman usually "feels life," the sensation often com- 
mencing suddenly and causing faintness or discomfort. It is 
caused by the fetal extremities striking against the inner walls of 
the uterus, or by a slower heaving motion of the trunk. At first 
these motions may be mistaken for contractions of the intestines 
or spasmodic movements of the abdominal muscles ; soon, however, 
they become more distinct, often disappearing for a time, and in a 
few cases being unrecognized by the mother during her entire 
pregnancy. This sensation of fetal movements is called " quick- 
ening," because it was thought in former days that at the time of 
their appearance the child became " quick," or alive. Fetal move- 
ments, when clear and definite, are positive symptoms of preg- 
nancy. 

5. Pigmentation. — An area of pigmentation forms around the 
umbilicus as early as the second month, extending downward in a 
narrow band (linea nigra) upon the median line of the abdomen. 
Moth patches (chloasmata) appear upon the forehead and sides of 
the face, and dark rings under the eyelids. These conditions are 
important only in connection with other symptoms. 



PHYSICAL EXAMINATION. 

In every case in which a physical examination for the diagnosis 
of pregnancy is attempted, it is essential that all outer clothing, 
corsets, skirts, and particularly waist-bands, be removed, the rec- 
tum and bladder emptied, that the patient lie down upon a firm bed, 
and the abdomen be covered with a sheet. The examiner stands at 
her right side facing her feet, making his manipulations with 
warm hands slowly and painlessly, so as not to provoke contrac- 
tions of the abdominal muscles and thereby interfere with their 
necessary relaxation. 

The examination should begin with palpation of the abdomen, 
followed by auscultation and percussion. Various methods of 
palpation are used, one of the best of these being to place the hand 
upon the tumor, parallel with its long axis, the palms together, the 
ulnar edges resting upon the skin, then to separate them laterally 



54 



THE PRINCIPLES OF OBSTETRICS. 



when the intervening body will be readily felt. Light pressure 
with the finger-tips will map out, in the later months, the head, 
extremities, and distinguish the firm back from the softer abdomen. 
Or while one hand steadies the tumor on the left side, the other 
makes intermittent pressure upon its right, pushing the foetus 




FIG. 26.— Method of Physical Examination. 



down upon the uterine walls where it can be felt and heard more 
distinctly. 

Auscultation may be immediate by the ear or mediate by the 
stethoscope, it being advisable to accustom one's self to use the ear 
direct rather than to rely upon the instrument, which might not 
be at hand when wanted. Every opportunity ought to be taken 
to familiarize one's self with the various sounds heard within the 
pregnant uterus. For diagnosis at any time after the fourth 
month, and specially at term for finding the presentation and 
position, the trained ear is surer, and certainly safer, than digital 
examination by the vagina. 

The situation of the intestines relative to the uterine tumor is 
shown by dulness on percussion along the median line of the 
abdomen and for a distance upon either side. Occasionally the 



SYMPTOMS OF PREGNANCY. 



55 



tympanitic note of the intestines may be heard over the uterus, 
where they have covered its anterior surface. 

The trained ear will hear various sounds within the pregnant 
uterus, recognizing them as posi- 
tive symptoms of the vitality of 
the foetus, and its position in the 
cavity. These sounds will be con- 
sidered in the order of their rel- 
ative value. 

i. Fetal Heart Sounds.— Pul- 
sations of the fetal heart can be 
heard with a stethoscope in the 
vagina as early as the twelfth 
week, and by abdominal ausculta- 
tion between the fourth and fifth 
month. At first only a confused 
murmur is recognized, the char- 
acter becoming more distinct with 
each succeeding week, and closely 
resembling the ticking of a watch 
under a pillow. The sound is 
audible over a space of about three 
inches, the rate being from 1 20 to 
1 50 beats per minute, each beat FlG - ^.-Focus of Auscultation. 1, ver 

. tex presentations, O. L. A. and O. L 

being double like that of the adult p. 
heart, the reduplication distin- 
guishing it from the single beat of 
the maternal aorta. The centre 

of loudest tone, or the "focus of auscultation," varies in the ab- 
domen with the position of the foetus ; in cephalic presentations 
being below and to the left or right of the umbilicus, in breech 
presentations above and on either side of it, and in transverse 
positions near the symphysis. Fetal heart sounds are absent in, 
or obscured by, hydramnios, very thick abdominal walls, and in 
posterior positions of the trunk. If not heard at the first trial 
another test should follow in a few days ; and if still absent in 
undoubted pregnancy the foetus is probably dead. 

The rate per minute of fetal heart sounds was formerly 




vertex presentations, O. D. A. 
and O. D. P. ; 3, breech presenta- 
tions, S. D. A. and S. L P. ; 4, breech 
presentations, S. L. A. and S. D. P. 



56 THE PRINCIPLES OF OBSTETRICS. 

thought an index to the sex of the foetus, it being a male if under 
140, but if over that number a female. This symptom is now 
known to be unreliable, the slower rate merely indicating a strong 
child of either sex, and vice versa. 

The fetal heart sounds are positive of pregnancy, and per 
contra, their absence is no proof that it does not exist. In order 
to hear them, have the patient lie down with the abdomen covered 
only with a thin cloth. Use the ear in preference to the stetho- 
scope (timid women are always afraid of instruments), auscultat- 
ing the left lower zone of the abdomen first, then the right, and 
lastly the upper half. If the sound is not recognized at the pe- 
riod of gestation when it should be, repeat the examination soon 
after; but if clearly audible the woman is certainly with child. 

2. Uterine Souffle. — After the fourth month, a bruit synchro- 
nous with the mother's pulse can usually be heard in the lateral 
regions of the uterus, louder on the left side, and probably caused 
by the current in the uterine arteries. It was formerly believed 
to be produced in the placental sinuses, but this idea is evidently 
incorrect, since the bruit persists for some time after delivery. 
The sound is unreliable in character, audible in one examination, 
absent in another, and at present not considered of much diag- 
nostic value, because it is heard in uterine fibromata and ovarian 
cysts as well as in pregnancy. 

3. Funic Bruit. — Sometimes a high-pitched hissing bruit may 
be heard in the gravid uterus, supposed to be caused by some 
obstruction to the current in the umbilical vessels, and if distinct 
is a positive sign of pregnancy. 

4. Ballottement. — The presence of the foetus in the uterus, 
when still small enough to move about freely in the amniotic fluid, 
may be assured between the fifth and seventh months by internal 
ballottement. This manoeuvre is accomplished with the patient 
in a position midway between sitting up and lying down, with 
clothing loose and bladder empty, or when standing before the 
examiner, a rather indelicate position. The uterus is steadied by 
the external hand, and when one or two fingers in the vagina 
make sudden quick pressure against the lower part of the uterus 
just above the cervix, the foetus will be tossed up and rebound 
upon the finger in a very characteristic manner. Ballottement, if 



SYMPTOMS OF PREGNANCY. 57 

correctly performed, is almost a positive sign of pregnancy, the 
possible exceptions being a small cystic ovary with long pedi- 
cle, advanced extra-uterine fetation, or stone in the distended 
bladder. 

5. Choc Fetal. — Occasionally the foetus may be heard to strike, 
during auscultation, against the uterine walls, the sound being 
like that artificially produced by "gently percussing one hand 
held flat against the ear with a finger of the other hand." It is 
ballottement heard by the ear rather than felt by the finger. 

6. Movements of the Foetus in Utero. — These are recognized 
both by inspection and palpation, either as a quick blow of the 
extremities against the uterine interior or a slower heave of its 
body. Simple pressure of the hand upon the abdomen will usually 
arouse them ; if not, the touch of the cold hand or ear of the exam- 
iner rarely fails to do so. Fetal movements may be unaccount- 
ably absent for a time, but when seen or felt are positive signs of 
a living child. 

7. Intermittent Uterine Contractions. — Feeble contractions of 
the impregnated uterus begin as early as the twelfth week, and 
even if not appreciated by the woman are readily felt by the hand 
of the examiner. They recur irregularly throughout the whole 
of pregnancy at brief intervals, lasting from two to five minutes, 
usually responding to the simple weight of the hand. If not, wet 
the hand with cold water and grasp the fundus firmly, when a con- 
traction will generally follow. Examination should be made with 
the patient recumbent, the rectum and bladder empty, and the ab- 
domen covered with a thin towel. Excluding contractions due to 
other causes than pregnancy, such as retained blood clots, fibroids, 
etc., intermittent uterine contractions add strength to the other 
symptoms of pregnancy. 

8. Bluish Color of the External Genitals.— After the last half 
of gestation the mucous membrane of the vestibule and vagina 
deepens in color, taking on a purplish tinge, compared to the " lees 
of wine," the ordinary vascular hue intensifying under the con- 
gestion of the pelvic vessels. It is most marked upon the inner 
surface of the labia majora and the anterior wall of the vaginal out- 
let, sometimes being restricted to the fossa navicularis and deeper 
parts of the rugae of the vagina. It has been recognized as early 



58 THE PRINCIPLES OF OBSTETRICS. 

as the fourth week, but is only a suggestive sign of pregnancy, 
for it may be entirely absent or be due to some other condition. 

THIRD TRIMESTER. 

History. Physical Examination. 

i. Breast signs matured. i. Ballottement. 

2. Milk and colostrum. 2. Enlargement of abdomen. 

3. Lightening. 3. Enlargement of uterus. 

4. Striae gravidarum. 4. Changes in cervix. 

5. Varicosities. 5. Definition of fetal parts. 
6 Constipation and irritable 

bladder. 

HISTORY. 

1. Breast Signs Matured. — During the last three months of 
pregnancy most of the symptoms felt by the patient herself dur- 
ing the preceding trimester are strengthened. The breasts con- 
tinue to develop, the nipple becomes firmer and more prominent, 
pigmentation of the primary and secondary areola increases— in a 
word, the preparation of these structures for active work indicates 
that the foetus is approaching maturity. 

2. Colostrum and Milk. — Colostrum and true milk can usually 
be expressed from the breasts of gravid women, particularly mul- 
tiparas, in the weeks just preceding delivery. In older primiparae, 
after thirty years of age, there is often an entire absence of func- 
tional activity of the breasts during gestation, and in such indi- 
viduals lactation will probably be a failure. 

3. Lightening. — The uterus steadily enlarges, losing its pyri- 
form shape and becoming more oval, its long axis lying obliquely 
from right to left in the abdomen, owing to torsion of the uterus 
toward the right from pressure upon its left posterior side by 
the descending colon. The abdominal walls relax more in multi- 
paras than they do in primiparae, in whom there is often much dis- 
comfort from their distention, sometimes actual pain, from stretch- 
ing of the abdominal parietes at their attachments to the pelvis 
and ribs, or striking of the fetal extremities against the uterine 



SYMPTOMS OF PBEGXAXCY. 59 

cavity. The fundus reaches its highest position about two weeks 
before labor, then it settles down about the same distance, as the 
presenting part enters the pelvic inlet. By this descent intra-ab- 
dominal distention is much relieved, the diaphragm sinks lower in 
respiration, and the patient breathes easier. This is the condi- 
tion called lightening, and is an indication that labor is near at 
hand. 

4. Striae Gravidarum. — During this trimester ruptures in the 
derma and connective tissue appear upon the breasts, the abdomen 
(where they seem to radiate from the umbilicus outward), and 
upper sides of the thighs. These lines, striae gravidarum, are of 
various colors, shading from silvery white to pink or purple, 
and are permanent, being in after-life an indication of previous 
child-bearing. 

5. Varicosities. — Pressure of the heavy uterus upon the pelvic 
vessels results in obstruction of their circulation with oedema of 
the lower extremities and external genitals during the last weeks 
of gestation, and is to be expected in first pregnancies. Varicosi- 
ties of the veins in the legs and thighs, sometimes in the puden- 
dal vessels also, are more frequent in later gestations than in 
earlier. The subcutaneous tissue of the legs often becomes filled 
with masses of vessels, bluish or even black in color from venous 
stagnation, and ecchymoses in the skin, or free bleeding even, 
may occur. Evidently in such conditions, walking or standing is 
attended with discomfort and sometimes is impossible. 

6. Constipation and Dysuria. — The functions of the rectum 
and bladder are retarded by the pressure and weight of the uterus 
during the last weeks, and hemorrhoids and constipation are prob- 
able with frequent urination, the latter being specially annoying 
just before labor and prophetic of it. 



PHYSICAL EXAMINATION. 

1. Ballottement.— Ballottement fails after the seventh month, 
owing to increasing size of the foetus and to lessening of intra-uter- 
ine space. 

2. Enlargement of the Abdomen. — The abdomen steadily in- 



60 



THE PRINCIPLES OF OBSTETRICS. 



creases in size, projecting usually more to the right from torsion 
of the uterus forward upon its vertical axis. The patient puts 
on fat over the hips and flanks, and the umbilicus pouts above the 
level of the skin in the last weeks. 

3. Enlargement of Uterus. — The uterine tumor progressively 
enlarges both vertically and laterally, the fundus ascending about 

two fingers' breadth, by rough 
measurement, for each month, 
reaching the ensiform cartilage 
midway between the ninth and 
tenth month. Ten days before 
labor the uterus begins to set- 
tle in the abdomen, as the 
presenting part engages in the 
pelvis. 

4. Changes in Cervix. — 
Softening of the cervix ad- 
vances from the beginning to 
the end of gestation. In prim- 
iparae the canal remains closed 
except to the tip of the finger 
until actual labor, but in mul- 
tiparas it generally dilates 
through its entire length in the 
last month, the finger being 
sometimes able to touch the 
membranes and presenting 
part in the eighth month. The 
lips of the cervix are thinner in 
first than in later gestations. 
5. Definition of Fetal Parts.— During the last of this trimes- 
ter the foetus can be outlined by palpation, when the abdominal 
walls are relaxed and amount of liquor amnii is normal. In nor- 
mal vertex presentations the head can be felt as a hard round tumor 
engaged in the brim, the feet or knees in the upper right abdomen, 
and the firm curving dorsum distinguished on the left side from the 
softer abdomen on the right. Definition of these parts is more 
difficult when the mother's abdomen is fat or tense, in hydramnios, 




Fig. 28.— Position of Fundus, Cervix, and 
Abdominal Wall in the Several Months 
of Pregnancy. (Schaeffer.) 



SYMPTOMS OF PKEGXAXCY. 



61 



or in multiple pregnancies. Fetal movements are evident to sight 
as well as touch during the last three months. At the beginning 
of labor the head has settled well into the pelvis, or, if the latter 
is ample and the child small, fully to the outlet. 



CLASSIFICATION OF SYMPTOMS OF PREGNANCY FOR 
EACH TRIMESTER. 



First Trimester. 



HISTORY. 

1. Amenorrhoea. 

2. Gastric disturbances. 

3. Mammary changes. 

4. Nervous irregularities. 



PHYSICAL EXAMINATION. 

Changes in position and size 

of uterus. 
Softening of cervix. 
Hegar's sign. 



Second Trimester 



History. 
Gastric disturbances lost. 
Mammary changes increased. 
Uterine enlargement. 
Quickening. 



History. 

1. Mammary signs increased. 

2. Colostrum and milk. 

3. Lightening. 

4. Striae gravidarum. 

5. Varicosities. 

6. Constipation and irritable 

bladder. 



Physical Examination. 
Fetal heart sounds. 
Uterine souffle. 

3. Ballottement. 

4. Funic bruit. 

5. Fetal movements. 

6. Intermittent uterine contrac- 

tions. 

7. Bluish color of vagina and 

vulva (Jacquemin's or Chad- 
wick's sign). 

Third Trimester. 

Physical Examination. 

1. Ballottement. 

2. Enlargement of abdomen. 

3. Enlargement of uterus. 

4. Changes in cervix. 

5. Definition of fetal parts. 



6l> THE PRINCIPLES OF OBSTETRICS. 



CLASSIFICATION OF SYMPTOMS OF PREGNANCY AC- 
CORDING TO THEIR RELIABILITY. 

Positive Symptoms. 

i. Fetal heart sounds, \ 

2. Fetal movements, y after fourth month. 



3. Funic bruit, 



Probable Symptoms. 



1. Hegar's sign, after the second month. 

2. Ballottement, from fifth to eighth month. 

x. Softening of cervix, ) . . . , , 

J n , . , ' - sixth to eighth week. 

4. Change m shape 01 uterus, ) 

5. Colostrum, twelfth week. 

6. Blueness of external genitals, after twelfth week. 

7. Intermittent contractions of uterus, \ , . -. . 

' _ . «• , i r after fourth month. 

8. Enlargement of abdomen, j 



Suggestive Symptoms, in Connection with Preceding Classifi 

cation. 

1. Amenorrhcea, first three months. 

2. Gastric disturbance, from sixth to twelfth week. 

3. Mammary changes, throughout. 

4. Pigmentation, from middle period. 

5. Lightening, two weeks to ten days before labor. 

6. Varicosities, last months. 

The time set for these to be first recognized is relative not 
absolute. 



CHAPTER V. 

I. IRREGULARITIES OF PREGNANCY. II. DIF- 
FERENTIAL DIAGNOSIS OF PREGNANCY. 

I. IRREGULARITIES OF PREGNANCY. 

There is no fixed limit for pregnancy. Scientists have agreed 
upon an "expectation of life," and obstetricians speak of a "period 
of gestation," but such terms are approximate, not absolute. It is 
impossible to foretell the exact duration of pregnancy, because 
either the date of impregnation is unknown or, if a single coitus 
is accepted as fruitful, it must be evidently a matter of speculation 
whether the subsequent pregnancy will take its natural course. 
So little is definitely known of the physiology of child-bearing, 
how long after insemination impregnation occurs, or where in the 
birth canal it takes place, that the precise hour or day when 
embryonic life begins cannot be stated. Since menstruation is 
normally absent during gestation, it is a reasonable inference that 
conception begins soon after its last appearance. Moreover, 
experience shows that pregnancy, during the child-bearing period, 
follows the last menstruation, and will continue if undisturbed 
through ten menstrual periods, or 280 days. In some women, 
specially multiparas, labor begins exactly on time, that is, after 
precisely 280 days of arrested menstruation; in others it antedates 
or exceeds that number by a week or more. In primiparae, how- 
ever, it is a common observation that labor is often delayed for 
several days beyond the classical limit, probably because impreg- 
nation happened later in the menstrual month than was assumed. 

From theory and fact, therefore, the general rule is established 
that pregnancy will continue about 280 days, beginning to count 
from the first day of the last menstruation, a few days more or 
less in individuals being allowable. 

Naegele's Law. — Of the various rules for computing the dura- 

63 



64 THE PRINCIPLES OF OBSTETRICS. 

tion of pregnancy that of Naegele is the simplest, which is to count, 
backward three months from the first day of the last menstrua- 
tion and add seven days. To illustrate: first day of last men- 
struation, September 15th. Count back three months — August, 
July, June. Add seven days; 15 plus 7 equals 22; computed day 
of labor, June 22d. To allow for the excess of days over 28 in cer- 
tain months, it is advisable to add 12 days instead of 7 in using 
the rule, and thus the approximate, not absolute, length of preg- 
nancy may be obtained. 

If the supposed date of impregnation cannot be determined 
either from a single coitus, because of lactation, or other valid rea- 
sons, the date of quickening may be taken from which to estimate 
the duration of pregnancy. But as this sensation is frequently 
unrecognized by the patient, and may be present at any time be- 
tween the twelfth and twentieth week, the method is evidently 
of little value for this purpose. 

Something can be predicted of the duration of pregnancy 
from the height of the gravid uterus in the abdomen. The fundus 
is normally at the level of the symphysis at the end of the third 
month, at the umbilicus at the sixth month, and touches the 
lower end of the sternum ten days or two weeks before labor. 
This plan is also unsatisfactory, because the uterus may vary from 
the standard at these dates owing to deficiency or excess of liquor 
amnii, over-development of the foetus, multiple pregnane}', etc. 
Apparent shortening of the cervix precedes labor a day or two, 
and in this connection may be considered as suggestive of its 
advent. 

Missed Labor. — Obstetricians acknowledge the fact that in 
very exceptional cases labor may begin at the appointed day, 
continue for a time, and then stop, leaving birth uncompleted. 
Further history of these anomalies of parturition varies; the 
attempt may be repeated a month or more later, possibly succeed- 
ing with the birth of a massive child, living, or still-born from the 
severity of the delivery. Usually the child dies in utero and is 
retained there for varying periods, undergoing certain pathologi- 
cal changes according to the condition of the membranes. If 
these are unruptured the foetus becomes mummified, macerated, or 
fatty degeneration takes place, and after long retention it changes 



IRREGULARITIES OF PREGNANCY. 65 

very exceptionally into adipocere or a lithopedion; if ruptured, 
and air enters the uterus, putrefaction takes place, the softer fetal 
parts liquefying and escaping from the cavity, the hard parts being 
retained indefinitely, or finally expelled by ulceration through the 
vagina and rectum. Missed labor is usually due to ectopic preg- 
nancy, to pregnancy in one horn of a bicornate uterus, to obstructed 
cervix from cancer or other disease, to tumor, or to very great 
rigidity. 

For further discussion of this interesting subject the student 
is referred to standard treatises upon obstetrics* 

Prolonged Pregnancy. — Gestation may exceed the normal 
limit by several days or even a month, and the laws of civilized 
nations recognize the legitimacy of children born within three 
hundred and five days of pregnancy. These cases often require 
the most formidable operations for delivery, owing to the exces- 
sive size of the child. 

Signs of Recent Delivery. — For medico-legal and other reasons 
it may be necessary to inquire whether a woman has been recently 
delivered. Careful physical examination of such person would 
probably show some or all of the following conditions : Colostrum 
or milk in the breasts and areolar pigmentation, striae gravidarum, 
enlargement of the uterus, gaping and lacerations of the cervix, 
with injuries of the vaginal outlet. These may all be exception- 
ally absent, but their presence would be presumptive evidence of 
recent parturition. 

Multiple Pregnancy. — While women normally give birth to 
but one child for each gestation, occasionally this number is 
exceeded. The cause of multiple fcetation is not known, but it is 
undoubtedly hereditary, especially on the mother's side. Statis- 
tics show that twins are born once in about one hundred labors, 
triplets are rare (i to 7,910), and more than this number are 
among the curiosities of medical practice. These cases are dis- 
tinctly pathological in their influence upon the foetus, and ac- 
companied with irregularities in almost all the details of preg- 
nancy and delivery. 



* See also case of author in Am. Jour, of Obst, July, 1885, and Lusk's 
Midwifery," ed. 1894, p. 306. 
5 



66 THE PRINCIPLES OF OBSTETRICS. 

Etiology. — Twins may result from the impregnation of (i) a 
single ovum, the germ dividing, (2) two distinct ova developing 
in one Graafian follicle, exceptionally (3) two ova expelled from 
different portions of the same ovary, or (4) two ova each belong- 
ing to a different ovary. Triplets originate from three single ova, 
or from unioval twins and a single ovum ; quadruplets from double 
twins or twins and two single ova (Jewett). Single ova produce 
foetuses of like sex, each having its own placenta and amnion, with 
a common decidua reflexa and chorion; with separate ova the 
sex is usually different, and there are separate placentae, chorions, 
and deciduae reflexae. Anomalies in placental circulation result 
in differences in size of the embryos, one may be a parasite of the 
other, the placentae may be abnormal in situation and number, 
and other irregularities from natural fetation are frequent. 
Plural gestation is usually shortened from excessive uterine 
distention, and emergencies in labor may be expected. 

Pseudocyesis (or spurious pregnancy). — In sterile young women 
who are very desirous of having children, in barren women near- 
ing the menopause, and in certain others specially of the hysteri- 
cal type, some of the suggestive symptoms of pregnancy may be 
present, though the uterus is unimpregnated. Difficulty of diag- 
nosis is greatest in the earlier months of supposed gestation, be- 
fore positive symptoms are likely to be present. The usual clinical 
history is of absent or scanty menstruation, some disturbance 
of the stomach, possible growth and sensitiveness of the breasts, 
with more or less abdominal enlargement. Vaginal examination 
will detect a virgin uterus, firm and of normal contour, the size 
not corresponding with that of the supposed period of pregnancy. 
At this time professional opinion may wisely be deferred until 
positive symptoms are present. In those cases in which abdominal 
enlargement is characteristic of advanced gestation many of its 
subjective symptoms are also present. Diagnosis is established 
by absence of fetal heart sounds or movements, and uterine 
contractions. Anaesthesia occasionally is necessary to clear up the 
doubt, but it is often impossible to persuade the patient that she 
is not pregnant. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 67 



II. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

Distinction between the gravid uterus and other pelvic and 
abdominal tumors is most difficult during the earlier months of 
gestation, when small growths like fibromata, ovarian cystoma, 
hydro- and pyosalpinx, etc., are liable to be mistaken for it. 
Diagnosis is largely by exclusion, it being remembered, first, that 
by far the most common abdominal tumor in women, within the 
child-bearing age, is the pregnant uterus, and second, that time 
solves all doubts. 

General Rules. — I. Amenorrhcea is the rule in pregnancy, in 
pathological growths the exception. 

II. Development of the gravid uterus does not correspond 
with the rate of growth of other tumors. 

III. Positive signs of fetal life distinguish the gravid uterus 
from all other massive abdominal enlargements. 

Special Rules. — Pregnancy. — During its first half, the uterus, 
without other associated growths, has its normal place in the 
pelvis; firmness, bulging of the lower segment, and Hegar's sign 
are present, size corresponds to the duration of the amenorrhcea, 
and clinical symptoms of gestation are probable. Pregnancy 
with other uterine growths is specially perplexing, and often diag- 
nosis must wait for time. Such tumors are usually irregular in 
shape, larger than natural for the particular term of gestation, 
clinical history is confusing, and menstruation may be present or 
absent. During the last half, if fetal sounds and movements are 
distinct pregnancy is absolute. 

In the following pathological tumors positive signs of preg- 
nancy are absent, unless mentioned as complications : 

Inflammatory Growtlis. — Ovarian and tubal inflammation gives 
history of previous illness, chills, fever, pain, etc. If unilateral, the 
tumor can be mapped out distinct from the uterus and outside of 
the round ligament. If bilateral, the pelvic exudate gives a board- 
like feeling to the vaginal vault into which the rigid cervix projects. 

Extra-ttterine Gestation. — A small, rapidly growing, lateral 
tumor, independent of the uterus, quite sensitive, menses scanty 
or absent, with discharge of decidua, is symptomatic of extra- 



68 THE PRINCIPLES OF OBSTETRICS. 

uterine gestation. If associated with normal gestation, differen- 
tiation is ordinarily impossible, and judgment must be suspended. 

Fibromata. — Rare with pregnancy. If mural, the uterus is 
harder than natural for pregnancy, its shape is irregular ; menor- 
rhagia or metrorrhagia instead of amenorrhcea is present ; signs 
of pregnancy are absent. If subperitoneal, the tumor can usually 
be distinguished from the uterus by the space between them and 
each has independent movement. If associated with pregnancy, 
diagnosis is very difficult or impossible, and fibroid may not be 
suspected until delivery. 

Ovarian Cystomata. — If small they are usually perceived first 
laterally, are soft, possibly fluctuating, have cyst-like feel; the 
uterus is displaced to one side, back, or front ; menstruation is 
usually present, and there is increasing dysmenorrhcea. If mas- 
sive, fluctuation wave is distinct but absent in the gravid uterus ; 
tumor more lateral if monolocular, fetal sounds wanting, fades 
ovariana, uterus normal. From multiple pregnancy or hydram- 
nios the diagnosis is often impossible, but the combination is rare. 
(In case of the author multilocular colloid ovarian cyst was not rec- 
ognized until after delivery, when it required cceliotomy for rup- 
ture.) 

Obesity. — Fatty abdominal tumor is usually associated with 
increase of bodily weight or general corpulence, often anaemia; 
appearance different from gravid uterus ; the walls of the abdomen 
can be caught up between the hands ; generally amenorrhcea or 
scanty flow is present ; uterus is natural in size and tension. Ex- 
perience shows that young, fat women are frequently sterile. 

Tympanites. — The size of the abdomen varies during the day 
and is smallest in the morning ; former history of gastric or intes- 
tinal indigestion, tympanitic resonance; no tumor felt on deep 
pressure. 

Ascites. — The abdomen is flattened and resonant in the median 
line, bulging and dull on the sides ; the level of dulness changes 
with position on the side ; previous history of cardiac, hepatic, or 
renal disease associated with the abdominal dropsy. Ascites with 
pregnancy, recognized by positive signs of latter; tumor unac- 
countably large or distorted ; emaciation and cachexia to be ex- 
pected. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 69 

Distended Bladder. — Dribbling of urine ; pain over bladder ; 
quick growth ; diagnosis by the catheter. 

Psendocyesis (or spurious pregnancy). — Diagnosis is established 
by anaesthesia. 

Hcematometra (menses retained in uterus). — Usually before 
puberty ; monthly growth ; uterine colic and contractions ; former 
history of congenital or traumatic atresia of vagina and cervix ; 
very rare. 

Physometra (gas in uterus). — Results from decomposition of 
organic matter retained in the uterus by obstruction of outlet ; slow 
growth and tumor never large, resonant ; uterus light in weight. 

Hydrometra (fluid in uterus). — Usually after menopause from 
accumulation of fluid in uterus and closure of cervix, tumor never 
large. The last two conditions are very rare. 



PART III. 

HYGIENE AND DISEASES OF 
PREGNANCY. 



CHAPTER I. 
HYGIENE. 

The laws of health in pregnancy are few and simple : live well, 
take plenty of exercise, empty the intestines every morning, 
consult the physician often, do not worry. 

While in the large majority of women gestation is a physiologi- 
cal function, under the manner of life of the present day Disease 
may usurp the place of Nature, and the simplest ailment initiate 
the gravest emergency. The pregnant woman, therefore, should 
be urged to place herself early under the supervision of her physi- 
cian, who knows the signs of danger as well as its remedy. Every 
primipara needs careful oversight, particularly the very young 
and old. Good obstetrics implies not only a happy delivery, but 
also an intimate acquaintance with the patient from impregnation 
to the end of the puerperium. 

Diet. — The extremes of pregnancy are specially modified by 
diet. Ordinarily during gestation women need not make any 
great change from their usual fare, eating such articles as are 
agreeable and customary. During the season of morning sick- 
ness food should be taken often through the day in small amounts, 
the kind not being so important as the variety, fruit and vege- 
tables forming a large part of the menu. Water, either plain or 
aerated, ought to be drunk freely ; tea in excess adds to the usual 
constipation and should be restricted, while coffee is useful before 
rising in the morning and at breakfast, its refusal being often 
an unnecessary self-denial. During the last weeks of gestation 
primiparae should eat sparingly of meats, and not at all if there is 
headache, albuminuria, decreasing urea, or other indications of 
toxaemia. 

Exercise. — The kind and amount of physical exercise is im- 
portant. It should preferably be in the open air, though many 
women get enough and to spare in their ordinary housework ; but 

73 



74 THE PRINCIPLES OF OBSTETRICS. 

sweeping, housecleaning, with some of the like occupations of the 
thrifty housewife, ought to be denied, particularly during those 
weeks when menstruation would ordinarily be present. Indoor 
painting is liable to provoke abortion or miscarriage, from the ec- 
bolic action of the turpentine. Bicycling, dancing, horseback rid- 
ing, or anything that causes sudden jarring or jolting of the body, 
lifting heavy weights or older children, are among the dangerous 
varieties of exercise. Every woman is, however, a law unto her- 
self, and many of the laboring class continue their necessarily 
hard life safely, even up to the hour of labor. 

Defecation and Urination. — At least one daily evacuation of 
the bowels should be insisted upon, and should be induced by suit- 
able diet, if possible without drugs. Water is the best diuretic, 
being usually all that is necessary, with the exception of adding 
bitartrate of potassium (the ordinary cream of tartar of the house- 
hold) to correct any dysuria. Urinalysis during the last weeks of 
gestation in primiparae is essential, as will be described later on. 

Care of the Breasts and Nipples. — Every woman is expected 
to nurse her child, except for reasons of evident deformity of the 
nipples and breasts or of constitutional disease. At the time of 
the morning bath they should be washed with soap and water, the 
nipples being made supple by careful traction. Astringent appli- 
cations like alum and alcohol provoke cracked and fissured nip- 
ples; daily inunction with cocao butter or clean lard is more 
suitable. 

Bathing. — The habit of bathing varies so widely in different 
portions of this country that care should be used in directing the 
daily bath. Speaking generally, a morning sponge bath or full 
bath at night may be advised, but good reaction must afterward 
be established by thorough friction with the towel. Very hot 
baths at any time are injurious, because the heat may stimulate 
uterine action. 

Dress. — Comfort should decide the dress rather than fashion. 
Corsets must be given up after the abdomen begins to be dis- 
tended. Skirts should be fastened by buttons to a corset cover 
or under-waist, their weight being carried from the shoulders 
rather than from the hips. A useful support for a pendulous ab- 
domen, or for the uterus when it sags down in the pelvis, can be 



HYGIEXE. 75 

made at home according to the Butterick pattern of abdominal 
bandage. 

Birth Canal. — Vaginal douches, if customary before pregnancy, 
may be continued during it if desired, but are usually unneces- 
sary. They should be taken from a fountain syringe or douche 
can, suspended a foot above the hips, and in the half-reclining 
position. The water should be blood-warm, plain, or with the 
addition of common table salt, bicarbonate of sodium (ordinary 
household saleratus), boric acid, or lysol (one teaspoonful to 
the quart). 

Marital Relations. — Coitus during gestation, though unphysio- 
logical, cannot be altogether restricted, but the husband should 
be advised of its danger, specially at the menstrual seasons. It is 
considered by all authorities provocative of abortion and gastric 
disturbance in the early months of pregnancy, and of miscarriage 
in the later months. 

Dangers of Infection. — Pregnant women should be informed 
that they are specially liable to septic infection from persons hav- 
ing, or just recovering from, such diseases as scarlatina, diphtheria, 
erysipelas, etc., particularly just before and after delivery. 

Author's Note. — A patient of the author's lost her child when it was 
ten days old, and was herself dangerously ill at the same time, from 
erysipelas, contracted from a kiss given by a friend just convalescing 
from that disease. 



CHAPTER II. 
DISORDERS OF PREGNANCY. 

The diseases of pregnancy are either local or general. Some 
are mere exaggerations of its physiological symptoms ; others are 
disturbances of related organs, from sympathy in the earlier 
months or from pressure in the later, or, are the ordinary constitu- 
tional ailments modified by the associated gestation. 

They include in variety any disorder to which a woman is liable 
when not pregnant, as well as those due immediately to that con- 
dition. Their etiology is the same in the one situation as in the 
other ; sometimes plain, at other times obscure, but commonly fol- 
lowing established rules. The diagnosis may be the simplest, or 
may baffle the most expert. Prognosis also may be uninfluenced 
because of the condition, or a fatal termination be inevitable. 
Finally, the therapeutics of pregnancy, while usually that of a 
similar disease in the unimpregnated, may require modification to 
suit the immediate complication. 

The pathology of pregnancy, therefore, is complex and exten- 
sive, requiring its present discussion to be restricted by obvious 
limitations of space. 

DISORDERS OF THE BIRTH CANAL. 

Diseases of the Gravid Uterus. 

Displacements. — The gravid uterus is liable to displacements, 
alike in character and situation to that of the unimpregnated 
organ — backward, forward, to either side, or downward. Torsion 
upon its vertical axis is physiological within certain limits, and 
very exceptionally the uterus may be included in ventral and 
inguinal hernias . 

Retroversion and Retroflexion. — Backward displacement of 

76 



DISORDERS OF PREGNANCY 



11 



the gravid uterus is more frequent than forward, either being dan- 
gerous from the chance of incarceration. The causes ordinarily 
are a continuance of a former 
malposition, falls and other in- 
juries, retrodisplac^ment being 
more common with contracted 
than normal pelves. 

Symptoms. — Dysuria in the 
early weeks of pregnancy is the 
most important symptom, and if 
associated with backache, pelvic 
pain, or hemorrhage from the 
vagina demands an immediate 
examination of that canal. Dis- 
placement backward is recog- 
nized by finding the fundus below 
the promontory in the hollow of 
the sacrum, the cervix near the 
symphysis pressing upon the 
bladder and urethra, with more 
or less prolapse of the posterior 




Fig. 29.— Retroflexion of Gravid Uterns, 
with Sloughing of Entire Mucosa of 
Bladder. (Schaeffer.) 



vaginal wall. 



Should the mal- 




FlG. 30.— Partial Retroflexion of Gravid 
Uterus, Resulting from a Total Incar- 
ceration. (Schaeffer.) 



position be not corrected at once, 
incarceration and grave compli- 
cations are liable. Signs of in- 
carceration are obstruction of the 
bladder and intestines from press- 
ure of the uterus upon them, 
followed, if unrelieved, by metri- 
tis, peritonitis, septicaemia, and 
death. 

Prognosis. — Early pregnancy 
is not usually disturbed, if spon- 
taneous or artificial restitution 
takes place at that time. During 
the first weeks spontaneous re- 
placement is customary ; but this 
failing, and the condition being 
neglected, abortion will occur, or 



78 



THE PRINCIPLES OF OBSTETRICS. 



incarceration, sacculation (enormous distention of the anterior 
wall with continuance of gestation), possibly voluntary attempts 
at delivery by discharge of the uterus through a rupture in the 
posterior vaginal canal will follow. Death is due to uraemia, rup- 
ture of the bladder, septicaemia, and errors in treatment. 

Artificial Replacement. — If spontaneous relief does not take 
place, put the woman in the lithotomy position, have the bladder 
and rectum empty, sterilize the hands and external genitals, make 

digital pressure within the va- 
gina or rectum against the fun- 
dus, pushing it around rather 
than against the promontory. 
If the attempt succeeds, support 
the uterus by a Thomas-Smith 
pessary or wool tampons until 
it has developed enough to re- 
main above the pelvis sponta- 
neously. If not successful, try 
the knee-chest or Trendelen- 
burg position, repeating the 
manipulations. Sometimes after 
digital pressure has failed, con- 
tinuous pressure by Barnes' 
bags or a colpeurynter for 
twenty-four hours will be more 
fortunate. In all these efforts 
anaesthesia is of material assis- 
tance, but if professional measures are ineffectual, abortion should 
be induced at once before incarceration occurs. 

After Incarceration. — Empty the bladder, which is usually 
obstructed by pressure of the cervix upon the urethra, with a 
male soft-rubber catheter, or, if this is impossible, by supra- 
pubic aspiration under the strictest asepsis. Then attempt reduc- 
tion as has been described, and if still unable empty the uterus at 
once. If the cervix is so high above the symphysis that it cannot 
be reached, two procedures are advised ; first, draw off the liquor 
amnii by puncture through the prolapsed uterine wall, when pos- 
sibly the lessened size will allow replacement and clearing out of 




PlG. 31.— Transition to a Prolapsus of a Re- 
troflexed. Gravid Uterus, with Perfora- 
tion per Rectum, per Vaginam, or 
through the Perineum. (Schaeffer.) 



DISORDERS OF PREGNANCY. 79 

the cavity ; or second, make vaginal hysterectomy. If infection 
has occurred, cceliotomy is the operation of election. 

Sacculation. — Retroflexion of the gravid uterus is very rarely 
spontaneously relieved by sacculation of the cavity, a division 
into two pouches takes place, the upper rising into the abdominal 
cavity and the lower remaining in the pelvis. Later the entire 
uterus may rise free in the abdomen and further pregnancy be 
normal, or if sacculation persists and abortion cannot be procured 
hysterectomy must be considered. Fortunately these complica- 
tions of gestation are rare, but if a capital operation is necessary 
favorable maternal prognosis may be expected under modern 
surgical methods. 

Anteflexion. — Forward displacement of the gravid uterus in 
the early months is usually due to adhesions from old pelvic in- 
flammations, or to operations for ventrofixation or suspension ; a 
number of the former cases have been recorded. Its symptoms 
are pain in the uterus and bladder, from attempts of these organs 
to rise in the abdomen, abortion following if the malposition is 
not relieved. Later in gestation forward displacement of the preg- 
nant uterus is due to relaxation of the abdominal walls, or to dias- 
tasis of the recti muscles in multiparas, whose pregnancies have 
been frequent and close together, and to shortening of the abdomi- 
nal cavity due to kyphosis and rachitic pelvis. 

Treatment. — During the first trimester attempts should be 
made to lift the uterus by tampons and massage. After the mid- 
dle period the pendulous abdomen is helped by suitable bandages, 
which lift the uterus rather than press upon it. 

Lateral Displacement. — This is usually congenital and com- 
plicates labor more than pregnancy, while right latero-version is 
the rule in the latter condition. 

Downward Displacement. — This malposition results from the 
increasing weight of the developing uterus, from relaxation of its 
supports, when pregnancy occurs in an already prolapsed and retro- 
verted womb, and exceptionally from straining and traumatism. 

Treatment. — While the uterus is yet small, spontaneous replace- 
ment is frequent, if not complete yet enough for gestation to con- 
tinue. If natural or artificial replacement is impossible, the only 
recourse is the induction of abortion and subsequent appropriate 



80 THE PRINCIPLES OF OBSTETRICS. 

treatment, or if the uterus is infected, vaginal hysterectomy. If 
the procidentia is neglected, incarceration may be expected, with 
possible gangrene, sepsis, etc. A completely prolapsed uterus 
will not carry the foetus to full term. 

Inclusion of the Gravid Uterus within a Hernia. — Among the 
anomalies of pregnancy is dislocation of the pregnant womb into 
a hernial sac, more often in ventral, less so in inguinal, and never 
in crural. In ventral hernia the uterus escapes between the recti 
muscles, or more rarely to one side of the abdomen, in inguinal 
hernia pregnancy is usually in a deformed uterus. 

Treatment. — Empty the uterus by podalic version and return 
it into the abdominal cavity ; if this is impossible, hysterectomy 
or Caesarean section will be necessary. 

Metritis. — Inflammation of the uterine muscle has usually pre- 
ceded impregnation, and is decidedly prejudicial to gestation, in- 
creasing the early reflex disturbance and often causing abortion. 
Its treatment is the same as that in a non-gravid uterus, but it 
may induce abortion. 

New Growths in the Gravid Uterus. — Different varieties of 
fibromata may coexist with pregnancy, developing at a correspond- 
ing rate with gestation, but are of obstetric interest only as they 
require operative attention for pain and pressure symptoms, or as 
they affect childbirth and the puerperium. Fibroids often dis- 
appear after delivery, associating with the uterine atrophy that 
characterizes involution. Cysts of the ovary, particularly der- 
moids, sometimes grow very fast under the stimulus of pregnancy, 
occasionally demanding immediate removal because of the pain, 
abdominal distention, and dyspnoea. 

Cervical Diseases during Pregnancy. 

Inflammation. — Cervicitis and endocervicitis increase the 
nausea and reflex distress of gestation, and possibly cause them. 
Intractable leucorrhcea often results, sometimes bloody discharges 
from the vagina, the latter occurring particularly at the menstrual 
periods, and offering an explanation for the supposed menstrua- 
tion of pregnancy. 

Cancer. — Statistics show that cancer of the cervix complicates 
pregnancy once in two thousand cases (Hirst). It occurs most 



DISORDERS OF PREGNANCY. 81 

often in multipara, having the ordinary symptoms of bleeding, 
offensive discharge, and pain, with its course and extension de- 
cidedly hastened by the gestation. Abortion, missed labor, spon- 
taneous rupture of the uterus, and placenta pravia are obstetrical 
emergencies depending upon this disease. 

Prognosis. — Eight per cent die undelivered, and forty-three 
per cent during or immediately after labor. 

Treatment. — If discovered in the beginning of gestation an im- 
mediate hysterectomy should be performed in operative cases, 
the foetus being sacrificed. After viability, the elective operation 
is Caesarean section. 

Diseases of the Vagina during Pregnancy. 

Diseases of the birth canal below the cervix are due to in- 
creased vascularity or infection. 

Vagina. — Leucorrhcea is often a distressing accompaniment of 
pregnancy, causing soreness and pruritus of the canal, and relieved 
(not often cured) by careful douching with solutions of bicarbon- 
ate of sodium, lysol (one-half of one per cent), and by other mild 
sedatives. Suppositories of tannin, ichthyol, alum, etc., are useful 
for excoriations. Laxatives are essential for constipation. A 
single application of a thirty-per-cent solution of glycerole of 
carbolic acid is highly recommended, or bathing the entire vagina 
through a cylindrical speculum with a twenty-per-cent solution of 
nitrate of silver, following with a douche of weak salt solution. 

GonorrJiccal vaginitis needs special attention because of its 
liability to infect the eyes of the child during birth. Disinfect 
the canal with a two-per-cent solution of nitrate of silver, per- 
manganate of potassium (one drachm to the quart), or bichloride 
of mercury (i to 2,000), followed by plain water. 

Vulva. — Vulvar pruritus of pregnancy is due to leucorrhcea, 
diabetes, lack of ordinary cleanliness, and may be a pure neurosis. 
Itching is distressing, sometimes unbearable, especially at night, 
and the genitals may be severely wounded in efforts for relief. 

Treatment. — Etiology should determine the treatment, which, 

it must be confessed, is largely empirical. Official preparations 

are to be preferred, such as douches of bichloride of mercury (1 

to 2,000) followed by plain water, or lysol (one per cent); bathing 

6 



82 THE PRINCIPLES OF OBSTETRICS. 

the parts with solutions of nitrate of silver (two per cent), satu- 
rated solutions of bicarbonate of sodium, acetate of aluminum 
(one-half of one per cent), or very hot water. A powder of sub- 
nitrate of bismuth, oxide of zinc, and boracic acid (of each one 
part), and starch (four parts), or simple talc powder, may help. 
Sometimes ointments are best, since they protect the parts from 
chafing and, if made with lanolin, the effect lasts longer ; newly 
made oxide of zinc with carbolic acid (one per cent, five grains to 
the ounce), orthoform (five per cent, twenty-five grains to the 
ounce), simple cerate, or boracic-acid ointment. Household 
remedies are legion. Occasionally the pruritus defies all thera- 
peutics, and induction of labor may be necessary to relieve the 
patient's suffering. 

Vegetations. — Condylomata about the vulva may grow pro- 
fusely during pregnancy, secreting an irritating offensive moisture. 
Ablation is liable to be followed by severe hemorrhage, and may 
terminate gestation. Astringent and antiseptic powders are 
palliative. 

Diseases of the Breasts. — Affections of the breasts and nipples 
during pregnancy resemble similar diseases in the non-pregnant 
woman, and are treated in the same manner. 



CHAPTER III. 

DIGESTIVE SYSTEM. 

MOUTH. 

Ptyalism. — Excessive secretion from the salivary glands occa- 
sionally accompanies the first months of pregnancy, sometimes 
persisting throughout the entire gestation. Etiology is obscure, 
though the condition is probably a neurosis, but the possibility of 
a toxaemic origin is acknowledged. The amount of saliva dis- 
charged varies from a little more than ordinary to several quarts 
daily. Gingivitis is rarely coincident, the gums being swollen, 
soft, and retracted from the teeth, which become loosened and 
sensitive. 

Treatment is empirical and disappointing. Ordinary mouth 
washes with belladonna (gr. ¥ ) or atropine (gr. j±-q) three times a 
day, pilocarpine (gr. y 1 ^) three times a day, extract of viburnum 
prunifolium (gr. iv.) every four hours, are indicated. 

Toothache. — Neuralgia of the teeth, with or without caries, is 
common in pregnancy, being supposed to be due to hyperacidity 
of the mouth and stomach, or to deficiency of lime salts because 
these are diverted to the needs of the child. The teeth should 
receive special care during pregnancy, minor operations for caries 
being less dangerous to its continuance than harassing pain. Mild 
astringent mouth washes, like tincture of myrrh, listerine, etc., are 
useful, with an occasional hypodermic of morphine for immediate 
relief, and the ordinary constitutional medication for neuralgia. 
Syrup of the lactophosphate of lime (one drachm three times a day) 
is advised for persistent dental caries during gestation. 

THE STOMACH. 

Nausea and Vomiting. — The most important affection of the 
digestive system during pregnancy is disturbance of the stomach, 
so often coincident with its commencement that it has come to be 

83 



84 THE PRINCIPLES OF OBSTETRICS. 

considered physiological. Hardly any two women are alike in the 
habit, some never being troubled with nausea and vomiting, 
others never being pregnant without them. It is more usual in 
the neurotic, in those who have previously had pelvic or uterine 
disease, in first pregnancies and multiple fetation, and large dis- 
tention of the uterus. Beginning ordinarily about the sixth week 
of gestation as an increasing nausea, with or without vomiting, it 
continues up to the end of the fourth month, and then normally 
stops, either gradually or suddenly. It is not uncommon for 
primiparae to begin vomiting immediately after impregnation, 
irritability of the stomach persisting at intervals up to term ; but 
vomiting during the last days of pregnancy is a grave symptom, 
suggesting eclampsia. 

Two forms of the disease are recognized : simple or physiologi- 
cal, and uncontrollable or pernicious (hyperemesis gravidarum). 
Distinction between the two varieties is one rather of degree than 
of kind, simple morning sickness exceptionally passing beyond nor- 
mal limits into the dangerous variety, whose composite symptoms 
are resistance to treatment and progressive starvation. Many 
practitioners of large obstetric experience have never seen a case 
of the grave form, even its existence as a distinct disease being 
questioned. Some authorities assert that there are but two forms 
of the disease, simple and exaggerated, and that pernicious vomit- 
ing during pregnancy is caused by some intercurrent disorder, like 
gastritis or ulcer. 

Etiology. — Its explanation rests upon the somewhat indefinite 
theory of reflex irritation of the stomach from distention of the 
developing uterus. Predisposing causes of pernicious vomiting 
are displacements and inflammatory conditions of the uterus (retro- 
flexions, metritis, endocervicitis, etc.) ; pelvic adhesions and dis- 
ease (salpingitis, appendicitis, peritonitis) ; in a word, any abnor- 
mality of structure, anatomical or pathological, that restrains the 
uterus from developing. Finally, emesis of gestation is believed 
to be due to auto-infection from retained toxins. 

Symptoms. — Simple gastric disturbance of pregnancy has been 
sufficiently described. It is accompanied by little or no pros- 
tration; food is well accepted at some part of the day, even 
if unwholesome or disagreeable at others, and the stomach re- 



DIGESTIVE SYSTEM. 85 

gains its normal tone, with little or no medication, after a few 
weeks. 

Pernicious or Uncontrollable Vomiting of pregnancy is gener- 
ally an exaggeration of the simple form, increasing in severity until 
all nourishment is rejected. The vomitus consists of mucus, food 
either or not digested, and bile with or without blood. There is 
usually epigastric pain with tenderness, the emaciation is progres- 
sive, the bodily temperature may be subnormal or increased, and 
the pulse rate from 120 to 140. Anorexia is complete, with sordes, 
coated tongue, and foul breath. Gastric ulcer is not an uncommon 
result of the disturbed stomachic nutrition, as is indicated by haema- 
temesis, that may of itself be fatal. As starvation lengthens, all 
these symptoms grow in severity : incontinence of urine, albumi- 
nuria and renal casts, heart weakness, delirium, and coma precede 
the fatal ending. 

Diagnosis. — If physiological nausea and vomiting become 
extreme, not readily yielding to treatment, thorough examination 
should at once be made. The pelvic organs should be methodically 
investigated for any abnormity of structure or function, like peri- 
toneal adhesions, metritis, uterine displacements, ovaritis, new 
growths, etc. Gastritis and other constitutional diseases, nephritis, 
hepatitis, malaria, for instance, should be looked for with all the 
skill possible. 

Prognosis. — A condition recognized as largely a neurosis must 
depend to a great extent upon the probable cause for prognosis, 
which is influenced by the severity of the exhaustion or the diffi- 
culty of feeding. Pernicious vomiting has a high mortality, vary- 
ing from thirty to sixty per cent, the severe cases usually being 
fatal. 

Treatment. — Professional management of the emesis of preg- 
nancy may be considered under three headings : hygienic, medical, 
and surgical. 

Hygienic. — An important factor in successful treatment is pos- 
sessing the confidence of the patient. Assurance that the gastric 
distress is annoying rather than dangerous, self -limited in duration, 
and that she will surely get well, often changes the querulous in- 
valid into the courageous burden-bearer. 

There can be no cast-iron rules for diet, since each woman is 



86 THE PRISCIPLE8 OF OBSTETRICS. 

in this respect a law unto herself. It is mainly a question of forced 
feeding with highly nutritious articles, concentrated in bulk, re- 
peated often through the day and in some cases through the night. 
Due appreciation of the financial status of the family must control 
professional advice about diet, since it is manifestly absurd to tell 
the laborer's wife to take her morning meal in bed, when she 
herself must prepare it. The peculiar meal at which vomiting 
occurs may be entirely omitted, and others make up for its ab- 
sence. If possible begin the day with a small cup of strong coffee 
without milk, and a slice of dry toast, dry bread, a meat sandwich, 
or cup of malted milk, remaining in bed for a half-hour afterward. 
Dry popcorn and ginger ale, strong coffee, champagne, milk with 
egg, and siphon soda are favorites with many at this time. Dur- 
ing the day eat early and often, a little at a time, not waiting for 
the set meal, cold foods being often retained when warm are re- 
jected. An explanation for the fact that the sickness of preg- 
nancy is more usual in the morning than through the day is this : 
food is taken at short intervals through the day, while there is 
abstinence for about eleven hours at night. Wake the woman, 
therefore, about one o'clock and have her eat something, when 
frequently the morning sickness will be avoided. With some pa- 
tients dry diet is best, with others soups and bulky viands are 
better. Water should be taken freely for its diuretic action and 
intestinal cleansing. Bathing also, either the full bath moderately 
warm or a good sponging with hot water at bed-time, quiets the 
nervous restlessness that predisposes to the stomach's fretfulness. 

If all feeding by the mouth is impossible, rectal alimentation 
should be tried, either the ordinary enema of milk, egg, brandy, 
and pepsin, or liquid peptonoids, beef juice, and pepsin, giving 
four to six ounces and repeating three to four times in the twenty- 
four hours. Hirst advises that " the rectum be washed out twice 
a day, and after the irrigation a pint of normal salt solution should 
be injected high up in the bowel for relief of the distressing 
thirst, that is a constant symptom." 

Medical. — Therapeusis of hyperemesis in pregnancy is largely 
a personal equation with the physician, as shown by the variety 
and extent of the drugs advised. It is undoubtedly better to rely 
upon a few of the simpler and approved remedies than to weary 



DIGESTIVE SYSTEM. 87 

the patient with polypharmacy. If sedatives are needed, use chlo- 
ral, bromides, cocaine, an occasional hypodermic of morphine, or 
liquid preparations of opium and codeine, in appropriate doses; 
if laxatives, blue pill, calomel and sodium triturates, cascara, aloes, 
belladonna, and strychnine pill at night, maltine and cascara be- 
fore meals; if alkalies, carbonate of magnesia in the lump, milk 
of magnesia, effervescent mineral waters, bicarbonate of sodium ; 
if acids, lemon and orange juice, cream of tartar lemonade; or 
gastro-intestinal sedatives and antiseptics may be indicated, bis- 
muth, oxalate of cerium, menthol, beta-naphthol, sulphocarbolate 
of zinc. 

Tincture of nux vomica or wine of ipecac, in minim doses every 
hour for a day or two, spraying the throat with a two-per-cent 
solution of cocaine, one or two minim doses of carbolic acid or 
creosote well diluted and repeated several times a day, ice packs 
or ether spray to the spine, have checked vomiting after other 
more rational medication has failed. 

There is opportunity for much ingenuity in drug experimen- 
tation with these patients, and the above list can be lengthened 
indefinitely. In pernicious vomiting it is essential that the woman 
be confined to a quiet room, under the care of a trained nurse if 
possible, and absolute rest of mind and body sought for. 

Surgical. — If therapeusis fails to control the vomiting, vaginal 
examination should be made, and manifest disease of the uterus 
and pelvis treated, always remembering that any local interfer- 
ence, even the simplest, may provoke abortion. Glycerin wool 
tampons for uterine congestion, pessaries for displacements, strong 
solutions of cocaine and chloral applied to the cervix, nitrate of 
silver, tampons of glycerole of ichthyol for erosions, are worthy of 
trial. The Copeman method of dilating the cervix with the finger, 
or, better, with the Goodell or Palmer dilator, has stopped per- 
nicious vomiting after failure of other measures. Tamponade of 
the cervix (Kehrer's method) may be tried, a funnel of gauze 
being pushed into but not through the cervix, and then filled with 
narrow strips of the same material. These operations act either 
by breaking up cervical strictures, nerve stretching, or from men- 
tal impression upon the patient. 

Finally the crucial experiment of emptying the uterus may be 



88 THE PRINCIPLES OF OBSTETRICS. 

necessary, when strength is evidently failing and symptoms of 
dangerous exhaustion, like temperature, heart failure, collapse, etc., 
are increasing. Unless religious scruples prevent, the foetus 
must be sacrificed before it is too late to rally the patient. All 
these desperate cases demand frequent consultation with experi- 
enced practitioners, since it is manifestly unwise for younger 
members of the profession to accept their responsibility unaided. 
It is better for his interests as well as for the family's to lose the 
child, rather than both child and mother. 

INTESTINES. 

The most important obstetric affections of the intestines are 
diarrhoea and constipation. 

Diarrhoea. — Increased peristalsis or mild catarrhal disturb- 
ances of the intestines during pregnancy are more common at the 
menstrual periods, and are usually reflex in character. Excessive 
action should be corrected early, since uterine contractions may be 
aroused thereby. Treatment is the same as for other varieties. 

Constipation. — Sluggishness of the intestines is characteristic 
of pregnancy, resulting from pressure of the uterus upon the 
colon and rectum, and possibly from deficiency of bile. Retention 
of fecal matters produces autointoxication, loss of appetite, and 
indigestion, while straining at stool to expel scybalae causes 
hemorrhoids and rectal prolapse. 

Treatment. — Generally speaking, treatment for constipation 
during gestation is similar to that for like conditions in the non 
gravid. Peristalsis should be stimulated by a coarse diet, like 
Graham and cornmeal bread, the coarser cereals, fruit in abun- 
dance, either fresh, or dried cooked in molasses, and plenty of 
water. Outdoor exercise is very beneficial in this respect. The 
habit of the morning defecation should be insisted upon, and 
encouraged by Hunyadi or Vichy water before breakfast. If 
actual constipation exists the milder laxatives may be taken at 
bedtime, frequent changes in the particular drug being made to 
prevent toleration. The most useful of these are preparations of 
aloes and cascara (as in the aloin, strychnine, and belladonna pill), 
or compound rhubarb pill, and compound liquorice powder. A 



DISEASES OF URINARY SYSTEM. 89 

valuable carthartic during the last days of gestation for primiparae 
with albuminuria is the Winckel pill (extract of aloes and extract 
of colocynth compound, of each gr. f , one to three every morn- 
ing). Enemata and glycerin suppositories are also serviceable. 

Appendicitis during Pregnancy. — A number of cases of appen- 
dicitis during pregnancy have been reported in which operation 
was necessary, pregnancy in some cases being undisturbed and 
in others prematurely ended. The mortality after operation is 
high. 

LIVER. 

The only hepatic disease particularly important during preg- 
nancy is acute yellow atrophy, which results from retention in the 
circulation of toxins that fail to be excreted by the usual emunc- 
tories. Eclampsia is accompanied by local degenerations of the 
liver, similar to those of phosphorus poisoning. 

Acute yellow atrophy of the liver is quickly fatal. Ordinary 
attacks of jaundice are relieved by calomel and other hepatic 
alteratives. 

DISEASES OF THE URINARY SYSTEM. 

Kidney. — Two varieties of kidney disease may be present 
during pregnancy — true nephritis, and the " kidney of pregnancy," 
the latter being more frequent and the symptoms less grave, while 
treatment is the same for both. 

The puerperal kidney results from overwork in eliminating 
material and fetal waste, its pathology being anaemia with fatty 
degeneration of epithelial cells, without acute or chronic nephritis. 

Etiology. — The cause is doubtless complex. Among the 
reasons assigned are general toxaemia from renal insufficiency, 
renal anaemia from abdominal tension, spasm of renal arterioles 
from reflex irritation, hydraemia with high arterial tension, climatic 
influences like taking cold, overdistention of the uterus from mul- 
tiple fetation or hydramnios. It is essentially characteristic of 
first pregnancies and most frequent during the last half of them. 

Frequency. — Six per cent of all pregnant women have some 
degree of albuminuria, the larger number in the last half of the 



90 THE PRINCIPLES OF OBSTETRICS. 

first gestation, and when appearing in successive pregnancies there 
is probably chronic nephritis. 

Symptoms. — These are usually associated with the last of the 
condition, and are more or less albumin, sometimes granular, fatty 
and hyaline casts, deficiency of urea, low specific gravity, and 
possible sudden lessening of the daily amount of urine ; oedema of 
the face and extremities, and uramic poisoning. Amaurosis is 
particularly significant of danger. 

Prognosis. — This depends upon the stage of gestation and 
extent of the toxaemia, and while all degrees of albuminuria are 
distinctly pathological, slight amounts are common and without 
especial danger during the last days of pregnancy; but in the 
early months they are more important, indicating premature kid- 
ney failure. Progressive albuminuria causes failure of the mother's 
health, loss of appetite, liability to eclampsia, and increases her 
susceptibility to septic infection, besides having a malign influence 
upon the foetus and inducing premature delivery. 

Treatment. — The obstetrician should always be on the lookout 
for albuminuria in primipara, routine examinations of the urine 
being made every week after the seventh month, and daily if there 
is progressive decrease in its quantity and solids with increase of 
albumin. In multipara urinalysis may ordinarily be deferred until 
symptoms of kidney insufficiency appear. If albuminuria is slight 
and decreasing, little active medication is necessary. Such food 
should be directed as makes least work for the kidney : milk, eggs, 
fruit, and water in abundance, and laxatives that produce watery 
stools. 

If the symptoms increase in severity, energetic treatment 
which diverts elimination to other organs is demanded. Meat 
should be restricted to once every other day, and entirely omitted 
by primiparae; milk is best taken in mouthfuls rather than in 
large draughts at once ; rare boiled eggs, fruit and light vegetables 
are proper, with water and cream-of-tartar lemonade. The bowels 
should be kept relaxed with salines, seidlitz powders, Hunyadi 
water, or the Winckel pill, and perspiration increased by warm 
clothing and frequent bathing. Tonics and heart stimulants are 
usually required, like Basham's mixture, caffeine, strophanthus, 
and digitalis. 



DISEASES OF THE URINARY SYSTEM. 91 

By agreement of the best authorities, failure of vision, nausea, 
and vomiting, and particularly epigastric pain, indicate threaten- 
ing eclampsia, and delivery should be immediate. Sudden lessen- 
ing of the daily quantity of urine, great oedema and sleepiness, are 
also indications for prompt interference with gestation. 

Glycosuria. — Glycosuria is next in frequency to albuminuria 
as a disturbance of the urine during pregnancy. " Physiological 
glycosuria " is common during gestation, being without pathologi- 
cal symptoms or influence upon either mother or child. True 
diabetes is rare during child-bearing, and is generally prejudicial 
to it ; abortion and miscarriage are frequent, as is early death of 
the mother after delivery. 

Symptoms. — Ordinary symptoms of true diabetes are present ; 
pruritus of the external genitals, hydramnios and dropsy of the 
foetus have been associated with the disease, with premature de- 
livery. 

Treatment. — Similar to other varieties. 

Bladder. — Irritable bladder is either a sympathetic disturbance 
of early pregnancy from distention of the growing uterus: me- 
chanical, from downward or backward displacement : or inflamma- 
tory, from septic infection or gonorrhoea. Urinalysis should de- 
cide whether the disease is functional or due to cystitis, symptoms 
of the latter being painful and frequent discharge of purulent urine, 
mixed with mucus and sometimes blood. In the last weeks of 
gestation, irritability of the bladder accompanies descent of the 
uterus into the pelvis in early engagement, and signifies the onset 
of labor. 

Treatment. — If from sympathy, nerve sedatives are required : 
suppositories of morphine and atropine for sleeplessness, and alka- 
lies for acidity of the urine. 

If from malpositions, replacement should be effected according 
to methods already described, urination advised in the knee-chest 
position, and if the bladder does not thoroughly empty, the soft- 
rubber catheter should be used. 

If from cystitis, the bladder should be irrigated with perman- 
ganate of potassium (i to 1,000"), boric acid (40 to 1,000); or 
prescriptions of salol, urotropin, bicarbonate of sodium, etc., should 
be given. 



92 THE PRINCIPLES OF OBSTETRICS. 

Hematuria, when present, is due to pressure of the gravid 
uterus, to calculus, or to excessive pelvic congestion. Astringents, 
irrigation, and postural urination are indicated. Cystic calculus 
should be removed before delivery, else a vesi co-vaginal fistula is 
liable. 

Incontinence. — Inability to retain urine is a common disturb- 
ance of pregnancy, from paralysis of the sphincter vesicae, over- 
distention of the bladder, coughing, etc. Incontinence of urine, 
besides causing discomfort from uncleanliness, produces excoria- 
tion of the external genitals. 

Treatment . — Strychnine, mix vomica, and chalybeates are 
indicated, with also frequent bathing with bicarbonate of sodium, 
boric acid, acetate of lead, etc. Ointments with a thick base, like 
lanolin, freshly made oxide of zinc, resinol, or simple cerate, are 
useful to soothe the abraded surfaces. 

DISEASES OF THE RESPIRATORY SYSTEM DURING 
PREGNANCY. 

Lungs. — Subacute bronchitis is frequent during pregnancy, 
cough being usually reflex in character, and important according 
to its severity. Abortion may be produced by it. An excep- 
tional danger during labor is acute pulmonary oedema, due to the 
constant straining of coughing. Treatment is palliative by the 
usual bronchial sedatives, codeine, the bromides, and ordinary ex- 
pectorant mixtures. 

Pneumonia. — Lobar or bronchopneumonia during pregnancy 
is decidedly aggravated in its course and prognosis, premature de- 
livery being a result of the high temperature, and the maternal 
mortality is large. 

Dyspnoea. — Distressing breatning during pregnancy is due to 
reflex irritation, to pressure against the diaphragm by the develop- 
ing uterus, or to cardiac disease. Treatment is palliative, and ex- 
ceptionally delivery is required. 

Phthisis Pulmonalis — Pregnancy increases the course of con- 
sumption, and hastens its development when latent. Women 
who are predisposed to tuberculosis, or who previous to marriage 
are its victims, should be cautioned against pregnancy. 



DISEASES OF THE CIRCULATORY SYSTEM. 93 



DISEASES OF THE CIRCULATORY SYSTEM DURING 
PREGNANCY. 

Heart. — Organic heart disease during pregnancy is one of its 
gravest complications, and whether existing previously or arising 
during gestation is made worse by the additional burden of fetal 
circulation. Mitral valvular lesions are more dnagerous than 
aortic, and stenosis than insufficiency ; the mortality of the for- 
mer is about thirteen per cent and of the latter about twenty-five 
per cent. 

Prognosis. — The amount of compensation determines the 
prognosis : advanced disease being generally fatal, abortion, prema- 
ture birth, and emergencies at delivery being quite common. 
Death during labor is often sudden and unexpected from failure 
to recognize the lesion beforehand. 

Symptoms. — These are the ordinary symptoms of embarrassed 
circulation : palpitation, dyspnoea, indigestion, failure of the func- 
tions of the liver and kidneys, albuminuria, dropsy, etc., depending 
upon the stage and extent of the disease and the frequency with 
which gestation is repeated. 

Treatment. — Pregnant women with cardiac lesions require the 
utmost watchfulness. Medical treatment is mostly symptomatic: 
compensation must be assisted by suitable heart tonics, a com- 
bination of strophanthus, trinitrin, and caffeine being especially 
useful. All violent exercise must be avoided, secretion and excre- 
tion encouraged in every possible way, and health maintained by 
the most careful supervision. 

Obstetrical treatment is always a source of much anxiety 
upon the part of the physician, since the result under the best 
management is often a failure. On general principles women 
with cardiac disease should be advised against marriage, and if 
pregnancy occurs it should be terminated as soon as possible, cer- 
tainly as early as the end of the seventh month. Delivery, even 
premature, is always dangerous, from sudden paralysis of the 
right heart due to overdistention. If pregnancy continues to 
term, labor should be conducted with as little exertion on the part 



94 THE PRINCIPLES OF OBSTETRICS. 

of the patient as possible ; dilatation should be assisted manually, 
Diihrssen's incisions of the cervix sometimes being necessary, 
all bearing clown should be discouraged and forceps applied 
early. Chloroform is the best anaesthetic, since ether increases 
the already dangerous pulmonary congestion. Strychnine, trini- 
trin, digitalis, or ether hypodermically should precede and follow 
delivery. 

The third stage is the especial time of danger, since additional 
blood coming from the uterine sinuses to the overburdened right 
heart may suddenly stop it. Moderate post-partum bleeding 
should be favored, venesection also being advisable if cyanosis is 
present. 

Personal experience of the author with several of these cases 
in private practice warrants his belief in their extreme danger. 

Palpitation and Fainting. — There are common reflex disturb- 
ances and pressure symptoms in the hysterical and neurotic, 
requiring no other particular treatment than rest, and mild seda- 
tives like the bromides, or valerian, while strychnine is rationally 
indicated. 

Hemorrhoids and Varices. — Venous engorgement and over- 
distention or disease of veins are common in multiparas and those 
of constipated habit. Varix of the saphenous veins is most fre- 
quent, next of the thighs and legs, least often of the vulva. 

Treatment. — Varicose veins of the extremities need careful 
bandaging or the elastic stocking to relieve pain or threatened 
rupture, the patient being taught how to arrest hemorrhage by 
suitable pressure, if rupture occurs. Medical treatment is pallia- 
tive. 

Hemorrhoids should be prevented by careful attention to the 
daily morning defecation and suitable laxatives, the best of which 
for this condition are preparations of sulphur (compound liquorice 
powder, or confection of sulphur), or the Fordyce Barker aloes 
pill, cold-water enemata, glycerin suppositories, etc. Ointments 
of belladonna, stramonium, cocaine, boric acid, and ichthyol will 
relieve pain.* 

*See paper by Webster, Amer. Jour, of Obst., October, 1894. 



DISEASES OF THE CIRCULATORY SYSTEM 95 



THE BLOOD IN PREGNANCY. 

Anaemia. — The quality of the constituents of the blood is often 
profoundly changed during the course of pregnancy, the tendency 
being to anaemia rather than to plethora, from contamination 
with unexcreted waste resulting from maternal and fetal metab- 
olism. In the earlier part of gestation there is an increase of the 
watery elements and leucocytes, with decrease of the red corpus- 
cles, the character growing richer during the middle portion as 
nutrition improves, and finally the necessities of haemostasis being 
supplied by relative excess of fibrin. Decided anaemia in preg- 
nancy has an injurious influence upon both mother and child, 
occasionally requiring premature delivery for alleviation. Per- 
nicious anaemia and leukaemia may originate during this condition 
as well as precede it, in either case being made worse and neces- 
sitating its termination 

Symptoms. — The usual symptoms of malnutrition are present : 
loss of appetite, general weakness and lassitude, shortness of 
breath, headache, neuralgias, chorea, and even insanity. Hydraemia 
is attended with dropsy of the extremities and genitals. 

Treatment. — Abundance of outdoor life and sunlight, easily 
digested food with red meats, eggs, milk, light wines or porter, 
iron if well borne (preferable in pill form), arsenic, bone marrow, 
and other ordinary restoratives. Nutrition may be assisted by 
rectal feeding. 

Plethora. — The opposite condition of anaemia is rare during 
pregnancy, having the usual symptoms : flushing of the face, full 
strong pulse, headache, tendency to nose-bleed, etc. If excessive 
there is danger of placental hemorrhages and abortion. 

Treatment. — The diet should be non-stimulating, meats and 
other hearty food restricted, and the general vascular pressure re- 
lieved by salines, or active cartharsis. Local bleeding may be re- 
quired by either venesection, leeches, or cupping for immediate 
relief. 



96 THE PRINCIPLES OF OBSTETRICS. 



DISEASES OF THE NERVOUS SYSTEM DURING 
PREGNANCY. 

Cerebral and Spinal Disease. — The pregnant woman, like any 
other, is liable to affections of the brain and spinal cord, the major- 
ity being coincidents rather than results of gestation, and exerting 
little or no influence upon it, good or bad. Apoplexy, myelitis, 
or paraplegia may precede or accompany the condition, and be a 
help to it instead of a hindrance. For instance, impregnation may 
occur in the hemiplegic, and pregnancy continue undisturbed, 
labor following an entirely natural course, with the advantage of 
being entirely painless. 

Neuralgias. — The peripheral nerves, especially the dental, 
often become diseased during gestation, and neuralgia of the 
abdominal walls from distention, or of the breasts as a result of 
development, is quite common. The great nerve trunks about 
the pelvis become painful from pressure of the gravid uterus 
or old inflammatory adhesions, sciatica frequently being very dis- 
tressing. 

Treatment. — The various neuralgias are treated upon general 
principles ; iron, arsenic, and strychnine for tonics, with the usual 
analgesics (phenacetin, acetanilid, codeine, local anaesthetics), and 
an occasional hypodermic of morphine. When evidently toxaemic 
in character, particularly if from renal failure, elimination should 
be encouraged by diuretics and cathartics. 

Chorea. — The chorea of pregnancy is of mild severity and 
most frequent in primiparae, usually originating in childhood and 
traceable to the ordinary causes — rheumatism, heredity, chlorosis, 
etc. 

Treatment. — If the disease seems to be aggravated by the 
continuance of gestation, it may be necessary to hasten delivery ; 
otherwise its treatment is similar to that for other varieties. 

Epilepsy. — The complication of epilepsy and pregnancy is 
rare, either being apparently without influence upon the other, 
convulsions not occurring during gestation, but reappearing in 
lactation or after the first menstruation. 

Insanity. — Insanity during pregnancy is either a continuance 



INFECTIOUS DISEASES DURING PREGNANCY. 97 

of a former condition, the result of various psychical derange- 
ments, or caused directly by its strain and emergencies. About 
one woman in four hundred becomes insane while child-bearing, 
from such reasons as the shame of illegitimacy, fear of desertion, 
sudden great mental shock, anaemia, or septic infection. In those 
of great nervous sensitiveness the most common time for its 
appearance is during the puerperium, as a consequence of the 
strain of delivery ; next during lactation, and least of all during 
pregnancy — acute mania, melancholia, and dementia occurring 
relatively in the order named. 

Prognosis. — Recovery takes place after two or three months 
in about two-thirds of the cases, the remainder becoming perma- 
nently insane or dying. 

Treatment. — Treatment is best carried out, if possible, at some 
institution where systematic nursing and restraint can be given. 
This failing or being impossible for good reasons, the plan of 
management at home is preferably a modified rest cure, thera- 
peusis being largely symptomatic, and nutrition assisted in every 
possible manner. Constant watchfulness is required to prevent 
the mother from injuring herself and child. 

INFECTIOUS DISEASES DURING PREGNANCY. 

The clinical features of infectious diseases, when complicating 
pregnancy, are uniformly ; extreme prognosis is grave, while treat- 
ment is ordinarily similar to that in the non-gravid condition. 
Hyperpyrexia reacts badly upon the foetus, causing placental 
hemorrhages and premature delivery ; or, if pregnancy unexpect- 
edly continues, destroys its vitality, death following soon after 
birth. Occasionally the child, after being infected in utero with 
some particular disease, is born with it in active progress, immunity 
during after-life being thus acquired. 

Only such details in this connection as are of obstetric inter- 
est will be mentioned. 

ACUTE INFECTIOUS DISEASES. 

Scarlatina. — Scarlet fever is rare during gestation, being 
more common during the puerperium. Abortion is likely, and 



98 THE PRINCIPLES OF OBSTETRICS. 

the child is sometimes born with the skin desquamating, indicating 
that it had had the disease before birth. One of its puerperal 
dangers is that of causing nephritis in the mother. 

Rubeola. — Measles is also rare during pregnancy; abortion is 
usual, and often fatal to the mother from post-partum hemor- 
rhage. Pneumonia is a frequent complication, prognosis in such 
cases being grave. 

Variola. — The confluent form is generally f atal to both mother 
and child, the risk being greater the more gestation has advanced ; 
the discrete form is less fatal to the mother but the child ordinarily 
dies. Many anomalies in the phenomena of the disease appear in 
the foetus ; it may have smallpox at the same time as the mother 
(shown after birth by pitting of the face), or escape the disease 
entirely ; the child may take it and the mother be immune ; in 
twin pregnancies, one child only may be infected. After abortion 
flooding is to be expected, and whether viable or not the child is 
usually stillborn. 

All pregnant women should be vaccinated at any period of 
gestation, except possibly during the last month, in the presence 
of an epidemic of smallpox. 

Varioloid during gestation is not especially dangerous. 

Cholera and Yellow Fever. — Either of these diseases associated 
with pregnancy is aggravated, and largely fatal to the mother, 
premature birth being the rule. Clinical history and treatment 
are similar to those in the non-gravid woman. 

Malarial Diseases. — The blood of the pregnant woman is as 
liable as that of any other to be infected by the plasmodium of 
malaria, any of its forms being present during gestation, while 
the child may show evidences of the cachexia in enlarged spleen 
and feeble condition. The ordinary treatment by quinine and 
arsenic is necessary, since the risk of their inducing abortion is 
less to be feared than the disease itself. 

Typhus and Enteric Fever. — Both are uncommon in preg- 
nancy ; prognosis is better for the mother than the foetus, which is 
usually aborted, or if carried to term is too much weakened to live 
for more than a few days. The especial puerperal feature of these 
diseases is a tendency to uterine hemorrhage from the high tem- 
perature. 



SKIN DISEASES DURING PREGNANCY. 99 

Syphilis will be considered in connection with diseases of the 
foetus. 

SKIN DISEASES DURING PREGNANCY. 

All parasitic diseases in gestation are relieved by thorough 
washing with green soap, or bichloride of mercury, and subse- 
quent rinsing with plain water. 

General Pruritus. — The affection is either a neurosis, or due 
to irritating secretions, glycosuria, or parasites, and while ordi- 
narily local rather than general may be very distressing. Abor- 
tion or even insanity may result from it, experience showing that 
it is worse at those periods when menstruation would have na- 
turally occurred if the patient had not been pregnant, and ends 
with delivery. 

Treatment. — The vulvar form has been sufficiently discussed. 
If a neurosis, treatment is by nerve sedatives, if from glycosuria 
by diet and local ointments, and if parasitic by germicides. Do- 
mestic remedies are very hot-water fomentations, saturated solu- 
tions of bicarbonate of sodium, vinegar, and infusions of tobacco 
(one-half drachm to the pint). Carbolic acid, menthol, and cocaine 
are the best of the professional aids. 

Herpes Gestationis. — A peculiar neurosis of pregnancy, most 
frequent in young women, localized upon the trunk, hands, or feet, 
and characterized by hyperemia of the skin, with large vesicles. 
Treatment is the same as for other varieties, with dusting pow- 
ders of boric acid, starch, talc, etc., or hot bran baths. 

LofC. 



CHAPTER IV. 

ABORTION, MISCARRIAGE, AND PREMATURE 

LABOR. 

ABORTION. 

Abortion is understood in obstetrics to mean the discharge of 
the production of conception before the sixteenth week of gesta- 
tion, miscarriage between this date and viability, and premature 
labor after viability and before full term. 

Varieties. — It is called spontaneous if involuntary, artificial 
if intentional, therapeutic if made for remedial purposes, and 
criminal if to escape maternity or for other wrong motives. 

Frequency. — All statistics are of no value in measuring the 
frequency of abortion, because the accident is often mistaken for 
menstruation, or concealed through shame and crime, but it is 
generally conceded to occur about once for every four preg- 
nancies. 

Etiology. — The causes are so numerous and various that they 
may be classified into: i. Paternal; 2. Maternal, subdivided into 
constitutional and local; 3. Fetal. 

1. Paternal. By far the most frequent cause from the father 
is syphilis, less often tuberculosis, alcoholism, extreme youth or 
old age, with others that have been mentioned. 

2. Maternal. Constitutional: Most of these have been given 
previously, but recapitulated are sudden great mental strain, sor- 
row, fright, shame, sight of another woman in labor (author has 
seen two such cases), epilepsy, chorea, and eclampsia; infectious 
fevers; traumatism; surgical operations of any kind; accidents, 
though the causative relation of the latter is often not so evident 
to the physician as to the patient ; and drugs taken accidentally 
or for criminal purposes. 

Local : Diseases of the pelvic organs, metritis, displacements, 

100 



ABORTION. 



101 



new growths, tubal and ovarian disease ; pelvic adhesions either 
inflammatory or surgical, like ventrofixation, and any gynaecologi- 
cal operation, even the tamponade ; excessive coitus ; and habit, 
which seems to be the only cause in some repeated abortions. 

3. Fetal. Death of the foetus; any pathological condition 
of the secundines like placental apoplexy, degeneration of the 

chorion; hyperpyrexia in fevers; 
septic infection, etc. 

Symptoms. — These depend 
somewhat upon the stage of gesta- 
tion, but more upon the complete- 
ness with which the secundines 
(placenta and membranes) are de- 
tached. The characteristic signs 
of abortion at any period of ges- 
tation are uterine contractions, 
hemorrhage, and expulsion from 
the vulva of the ovum, entire or 
fragmentary, rarely as distinct acts 
but usually parts of a continuous 
though interrupted process. 

Threatened Abortion. — At any 
stage of pregnancy, contractions 
of the uterus may be induced by 
some one or more of the causes 
enumerated, the symptoms re- 
sembling those of ordinary men- 
struation but without hemorrhage 
or opening of the cervix. Under 
appropriate treatment uterine 
action is arrested and the threatened abortion or miscarriage 
checked. 

Inevitable Abortion. — Should contractions persist with increas- 
ing hemorrhage and the cervix open so that the amniotic sac can 
be touched by the finger, it is probable that expulsion cannot be 
hindered. 

Actual Abortion before the Formation of Placenta.— Premoni- 
tory symptoms are slight, expulsion beginning with a little hemor- 




FlG. 32.— Commencing Abortion with 
Subchorionic Decidual Apoplexies. 
The largest apoplexy in the decidua 
vera represents the retroplacental 
haematoma arising from the separa- 
tion of the chorion. (Schaeffer.) 



102 THE PRINCIPLES OF OBSTETRICS. 

rhage, lumbar and sacral pain, and bearing down. At this time 
pain is not so prominent as the bleeding, the latter being continu- 
ous rather than excessive, and usually in the shape of clots. The 
entire process may be mistaken for natural menstruation, since 
the ovum generally escapes detection in the coagula ; but should 
it be recognized, the question of abortion is settled. The ovum 
will appear either as a delicate sac, with shaggy chorionic villi 
enveloping the embryo, or as a ruptured sac with embryo outside, 
or the membranes may be retained in utero and the embryo alone 
be expelled. Duhrssen says that the retention of some parts of the 
decidua vera is the rule, not the exception. Sometimes a fleshy 
sac of thickened decidua comes away, enclosing the embryo, or is 
empty; in the latter case the foetus dies and is absorbed, or is 
washed out unnoticed in the discharges. 

After the Formation of the Placenta. — During the third month, 
when the placenta is developing, abortion resembles a miniature 
labor at term ; pains are greater than in earlier gestation ; after 
more or less hemorrhage the foetus is expelled, the placenta not 
following for some hours or days. This imitation of the three 
stages of natural labor, dilating, expulsive, and placental, occurs 
in the majority of abortions and miscarriages at this period, divid- 
ing the process into two forms, complete or incomplete, according 
to the degree of retention of the secundines. 

Complete. — Ordinarily premonitory contractions increase with 
decided hemorrhage ; the cervix opens so that the examining finger 
can feel the uterine contents, and after a variable time, either 
minutes or hours, the entire fetal mass is expelled unbroken. 
There is a little lochia for a few days (depending in amount upon 
the stage of pregnancy), involution progresses kindly, and con- 
valescence is ended in a week. Cases like these are unfortunately 
rare. 

Incomplete or Neglected. — Pains and hemorrhage reach their 
acme with the expulsion of the foetus, which is now large enough 
to be recognized, and therefore settles the question whether it 
has come away. The delicate umbilical cord breaks, leaving the 
placenta and decidua within the cavity, which now acts as if the 
process was finished. The cervix closes, contractions and hemor- 
rhage cease, and the patient supposes herself to have completed 



ABOBTIOX. 103 

the abortion. But after an interval of hoars or days hemorrhage 
begins again, indicating that the cavity is not empty, continuing 
for a varying time and degree, and finally ending in discharge of 
fetal and decidual debris. Or the secundines may be retained 
indefinitely, become infected from the vagina, and metritis, 
salpingitis, or peritonitis follow — a clinical history that often ac- 
companies criminal abortions, procured by unclean hands and 
instruments. 

Still other, but anomalous, forms of abortion are those when, 
after apparent evacuation of the cavity, the uterus closes upon a 
fragment of the placenta or decidua, which continues growing 
until some time later a mass is expelled, called a placental polyp. 
In twin pregnancies one foetus may be aborted, and the other 
retained to maturity. 

Diagnosis. — The question of pregnancy should be settled 
first, by using the tests for it which have been given, after which 
it is necessary to distinguish between threatened and inevitable 
abortion. 

Threatened Abortion.— Slight hemorrhage with uterine pain 
during amenorrhcea indicates a probable abortion, particularly if 
upon questioning and examination evident symptoms of pregnancy 
are present. Returning menstruation is usually painless, but if 
hemorrhage and pain are increasing it might be mistaken for abor- 
tion, unless positive signs of the latter are found by detection of 
the foetus or secundines in the coagula. 

Inevitable Abortion. — Besides increasing hemorrhage and 
pains, if the cervix opens enough to admit the finger, abortion 
will ordinarily be inevitable, and is almost sure to follow large 
flowing or expulsion of any part of the fetal structures. 

Complete or Incomplete Abortion. — In either of these condi- 
tions, all discharges from the vulva should be examined under 
water if possible, especially coagula, shreds of tissue, and chorionic 
villi, as in this way only can one know just what has been accom- 
plished. If the discharges have been lost before such an inspec- 
tion, unfinished abortion is indicated on vaginal examination by 
dilatation of the cervix, by portions of the secundines caught in 
the canal, and by continuous flowing ; if complete and the uterus 
empty, the latter is firmly contracted with the cervix closed, and 



104 THE PRINCIPLES OF OBSTETRICS. 

bleeding soon ceases. In doubtful cases, diagnosis must rest upon 
the clinical history of the case, the lochial discharge, the pres- 
•ence of milk in the breasts, and possible septic infection with en- 
largement of the uterus. 

Ectopic Pregnancy. — Abortion in ectopic gestation is distin- 
guished from that in natural gestation by more intense pain, by 
discharge of fragments of decidua at irregular intervals, and by a 
sensitive lateral tumor ; but differentiation is possible exception- 
ally only by exploration of the uterine cavity. 

Prognosis. — The chief danger is from hemorrhage and retained 
secundines, depending also upon the stage of gestation. If early 
and complete, convalescence is uninterrupted ; if after the forma- 
tion of the placenta, incomplete or neglected, with long protracted 
hemorrhage, and particularly if infection has occurred or the 
abortion was criminal, prognosis is doubtful. Hemorrhage is 
rarely immediately fatal, but its sequelae (grave anaemia, septic 
infection, uterine or pelvic disease) are common and sometimes 
incurable. Therapeutic abortion should have no mortality. 

Treatment. Threatened Abortion. — Absolute rest in bed ; pain 
checked by morphine hypodermically, by rectal suppositories of 
opium, by enemata of laudanum in sufficient doses with chloral or 
bromides, or by fluid extract of viburnum prunifolium (one drachm 
every three hours). If pains cease, hemorrhage is slight, and 
cervix closes, the abortion will probably be arrested. 

Inevitable Abortion. — If it is evident that uterine action cannot 
be checked, then means should be taken to assist the expulsion. 
The time for rest in bed and opiates has gone by, and the ques- 
tion of immediate interference can properly be considered. Four 
plans of treatment of inevitable abortion are favored by the pro- 
fession: (i) Anaesthesia and prompt evacuation of the uterine 
cavity by the finger, curette, and placental forceps; (2) temporary 
plugging of the canal to check flooding and stimulate contrac- 
tions, and after some hours mechanical emptying of the cavity ; (3) 
tamponade and ergot, repeating the plugging until natural expul- 
sion occurs ; and (4) temporizing without operative interference, 
and use of drugs. 

Of these several plans, the last is mentioned only to be con- 
demned. No amount of medicine will clean off the decidua, the 



ABOETIOX. 105 

especial cause of the hemorrhage and infection, and besides, pre- 
cious time is lost in trifling with the health and life of the patient. 

The third plan should be reserved for those exceptional cases 
in which it is certain that the uterine contents have been expelled, 
subsequent operation depending upon the recurrence of hemor- 
rhage or signs of infection. 

Whether the foetus has or has not been expelled, if hemor- 
rhage is active, it is probably best for the ordinary practitioner, 
unaccustomed to gynaecological operations and without efficient 
nurses, immediately to tampon the vagina and thus save further 




FIG. 33.— The Sims Position. 



loss of blood, with the hope that contractions will be thereby 
stimulated, uterine contents spontaneously expelled, and further 
assistance be unnecessary. These are the early abortions, occur- 
ring before the formation of the placenta, and sometimes even 
after the fourth month. Ergot should be given for a week, or 
while the lochia continue, hot douches of normal salt solution 
advised night and morning up to the time of the next menstrua- 
tion, and iron with bitter tonics for restoratives. 

Incomplete or Neglected Abortion. — These are the perplexing 
cases, in which the question of active interference must be con- 
sidered. Without attempting to establish absolute rules, it is 
undoubtedly right to assume that immediate operation should be re- 



106 



THE PRINCIPLES OF OBSTETRICS. 



stricted to the expert, for whom the best plan of treatment of these 
cases is immediately to empty the uterine cavity under anaesthesia. 
The second plan is therefore better for general adoption. 
When called to a woman who is actively flowing and abortion in- 
evitable, before making the first vaginal exam- 
ination sterilize the hands as thoroughly as cir- 
cumstances will permit with ordinary soap and 
hot water, or if possible with the usual germi- 
cides: bichloride of mercury, permanganate of 
potassium, and oxalic acid, or with chlorinated 
soda, secundem artem. Have the patient uri- 
nate (or catheterize her) and empty the rectum. 
Place her upon a Kelly pad or protective of some 
kind, and carefully wash the external genitals of 
blood and coagula, clipping the hair if needed, 
and following with a hot normal salt solution 
douche. Then put her in the Sims position 
and pack the vagina through a Sims speculum 
(or the handle of a large spoon) with strips of 
gauze or boiled linen. Begin by plugging the 
cervix, if possible, then the posterior vaginal 
vault, continuing downward, filling the sides as 
well as the centre of the canal until the packing 
reaches to just within the vulva. If properly 
done, little blood will appear afterward, while 
that shut up in the cervix will stimulate con- 
tractions. 

The patient may now be safely left for sev- 
eral hours, ergot being given to hasten uterine 
action, though usually strychnine and quinine 
are fully as useful for that specific purpose, as 
well as being general restoratives. The pack 
should be removed in from ten to twelve hours, 
with clean hands, when in the minority of cases 
the foetus and secundines will be found in the cervix or vaginal 
vault, from which they can be readily withdrawn by the finger 
or forceps. Local and constitutional treatment should follow, as 
has been indicated. 



Fig. 34.— Neilson's 
Uterine Irrigator. 



ABOBTIOX 



107 



Unfortunately, in a large proportion of cases the pack fails to 
empty the uterus, and after douching the vagina it may be repeated, 
but the better practice is immediately to explore the cavity under 
full anaesthesia. Asepsis should be carefully maintained in both 
operator and patient. Place her 
across the bed or table in the 
lithotomy position, using a leg 
bandage or twisted sheet to hold 
the legs. Draw down the uterus 
with a volsellum forceps, find its 
length and direction with a sound, 
and stretch the cervix, if closed, 
with a Palmer or Goodell dilator 
wide enough to pass the fore- 
finger into the cavity. If the fun- 
dus cannot be reached (which is 
generally impossible), try to push 
it still further downward by the 
hand above the symphysis, and 
if successful the question whether 
or not the abortion is completed 
can be settled at once. If any- 
thing has been left in the uterus, 
remove it by the finger, whose 
tactile sense makes it superior to 
any instrument, or the ordinary 
sponge forceps, withdrawing the 
fragments in a rotary manner. 
After using a moderately sharp 
curette over every part of the 
interior, particularly the region 
about the cornua, wash out the 
debris with a uterine irrigator, and 
apply tincture of iodine upon a 
wrapped sound to the entire endometrium. Unless sharp hem- 
orrhage follows the curettement a uterine drain is unnecessary, 
and if used should be withdrawn in twenty-four hours. 

The author has used for many years a placental forceps, 




FlG. 35.— Warren's Placental Forceps. 



108 THE PRINCIPLES OF OBSTETRICS. 

devised by himself and shown in the cut. With ordinary care the 
secundines can be extracted by it without injuring the endome- 
trium. Whatever is grasped is held firmly and one blade can be 
substituted for a curette. 

Many minor points of detail in this description are omitted, but 
the operation, as set forth, is within the skill of any careful prac- 
titioner, and is uniformly successful in completing the abortion. 

MISCARRIAGE. 

The peculiar characteristic of miscarriage is liability to reten- 
tion of the placenta, an emergency that interferes with uterine 
contractions and involution, causing also malaise from exhausting 
hemorrhages, and frequently septic infection. The process is 
more like labor at term than abortion ; uterine contractions can 
be felt by the hand, pain is greater, and there is a distinct pla- 
cental stage, which is apt to be delayed from failure of the uterus 
to expel the placenta. 

Treatment depends upon the degree of retention of the pla- 
centa, which may require assistance in removal, similar to that in 
abortion. 

PREMATURE LABOR. 

Much that has been said relating to abortion and miscarriage 
applies to premature delivery. The most common causes are 
faulty attachment of the placenta, albuminuria, and syphilis, for 
which it is generally better to encourage rather than delay labor. 
Its treatment differs in no respect from parturition at term. 



CHAPTER V. 
EXTRA-UTERINE PREGNANCY. 

Extra-uterine or ectopic (" out of place") pregnancy is the 

development of the product of conception outside the uterine 
cavity. There are no reliable statistics from which to base its 




Fig. 36. — Extra-Uterine Pregnane; 



frequency, but it is certainly more common in practice now than 
formerly, owing to greater skill in symptomatology and diagnosis. 

The different forms are classified according to their location 
into: 

Tubular, subdivided into Interstitial, when the ovum develops 
in that part of the Fallopian tube within the uterus. 

Tubo-ovarian, when attached to the ovarian fimbriae. 

Tubal, when developed in the tube without extending into the 
uterus or abdomen. 

Abdominal, when it is supposed to develop in the abdominal 
cavity; and 

Ovarian, in a Graafian follicle. 

109 



110 THE PRINCIPLES OF OBSTETRICS. 

It is now recognized that tubal and ovarian pregnancy are the 
two primary forms, later stages being almost always extraperi- 
toneal. " The criterion of the nature of an extra-uterine preg- 
nancy is not the locus of the foetus, but the attachment of the pla- 
centa " (Berry Hart). The abdominal variety is always secondary 
from rupture of the tube and escape of the ovum into the abdomi- 
nal cavity, where it afterward develops. Ovarian pregnancy is 
very rare, only some twenty cases having as yet been reported.* 
Interstitial and cornual pregnancy (impregnation in one horn of 
a bicornate uterus) are rarely diagnosed except at operation, and 
these four last forms, being so unusual, will not receive further 
attention. 

In accordance with the design of this book, most of the space 
allotted to the subject of ectopic gestation will be devoted to its 
symptoms and diagnosis only. Standard treatises upon obstetrics 
should be consulted for its other details, including operative treat- 
ment. 

Etiology. — Tubal gestation is due to any cause that retards or 
arrests the progress of the ovum through the tube, such as les- 
sened peristalsis from destruction of its ciliated epithelia, strict- 
ures from previous inflammation, and congenital malformations. 

Symptoms. — These are divided into two classes, according as 
they appear (i) before rupture of the tube, and (2) after rupture. 

( 1 ) Before rupture. Pregnancy outside the uterus occurs most 
frequently between the ages of twenty and thirty, after long 
periods of sterility following natural childbirth or miscarriage, 
with many exceptions to the general rule. Menstruation may 
he either regular, absent, or scanty for one or two periods, fol- 
lowed by an excessive quantity, and pregnancy be not suspected, 
though its subjective symptoms are ordinarily present. Vaginal 
examination, if made before rupture, shows the uterus enlarged, 
though not enough for the period of amenorrhcea, the cervix patu- 
lous, and a tense, sensitive tumor lateral to and independent of it. 
Ballot tement ordinarily fails. 

*The only well established case of ovarian pregnancy in America, up 
to 1902, is that of Thompson, reported in the Transactions of the American 
Gynaecological Society for 1902. 



EXTRA-UTERINE PREGNANCY. Ill 

(2) After rupture. Immediately or soon after rupture there is 
progressive abdominal and pelvic pain, similar to that of intestinal 
colic or cholera morbus, for which it is often mistaken, followed 
by hemorrhage from the vulva at irregular times, generally with 
the pains. If internal hemorrhage is continuous and abundant, or- 
dinary signs of concealed bleeding appear: feeble, rapid, or loss 
of radial pulse, faintness, air hunger, extreme thirst, subnormal 
temperature, skin wet with cold perspiration, failure of kidney ac- 
tion, etc. Once witnessed, the picture is so appalling that it is 
never forgotten. 

A peculiar characteristic of extra-uterine gestation is the dis- 
charge of a decidua, either entire or in fragments, differing micro- 
scopically from that of normal pregnancy in having special de- 
cidual nucleated cells and no chorionic villi. Vaginal examination 
after rupture shows a soft, boggy tumor, lateral or posterior to 
the uterus (pelvic haematocele), and moderate peritonitis follows 
in a few days. 

Pathological History. — Tubal pregnancy ends in two ways : ( 1 ) 
further development is arrested by death of the foetus and its 
subsequent absorption, or (2) it grows in size much faster than 
the tube, which finally gives way, either from thinning of its 
walls by pressure of the ovular sac, or possibly from penetra- 
tion of their muscular fibres by chorionic villi. The future 
history of the second variety depends upon the situation of the 
rent. 

Extraperitoneal Rupture. — When the tube ruptures in that 
part covered only by the connective tissue which separates the 
peritoneal surfaces of the broad ligament, the effused blood is con- 
fined between its layers, a pelvic haematocele resulting, limited in 
size by the capacity of the space enclosed. Three terminations 
are possible : the foetus and blood clot are eventually absorbed ; 
infection occurs and abscess, which is retained indefinitely or dis- 
charged through various channels ; or the foetus may be preserved 
in the cavity even for years as a lithopedion, a calcareous mass, or 
it may become mummified. During any time of subsequent life 
these may be discharged by ulceration through the rectum, blad- 
der, vagina, or skin. Very exceptionally the placenta, uninjured 
by the rupture, attaches itself to the peritoneal surfaces of the 



112 THE PRINCIPLES OF OBSTETRICS. 

uterus or intestines, the foetus developing even to term, and form- 
ing one variety of abdominal pregnancy. 

Intraperitoneal Rupture. — The most common result of intra- 
peritoneal rupture is fatal hemorrhage ; but if this does not occur, 
changes similar to those of the preceding section take place, the 
foetus becoming encysted in the abdominal cavity and developing 
to term. Counterfeit labor follows, the child dies, and degenera- 
tive processes in it are set up, or, more commonly, it becomes in- 
fected, death of the mother succeeding from general sepsis. 

Diagnosis. Before Rupture. — The question of diagnosis has 
largely been anticipated in the previous sections. The condition 
is exceptionally recognized before rupture by the general practi- 
tioner, and at this time is perplexing even to the expert. Its 
clinical history is ordinarily that of amenorrhcea or irregular men- 
struation, early gastric disturbance, and mammary changes, but 
gestation is often entirely unsuspected. The uterus is not devel- 
oped quite enough for the corresponding period of normal preg- 
nancy ; it is displaced to one side, is empty when explored, and its 
cervix is patulous. These symptoms, while resembling those of 
an incomplete abortion (for which extra-uterine gestation is fre- 
quently mistaken), become clearer after further examination, 
which shows a tumor on the side, in front, or behind the uterus, 
of rapid growth, very sensitive, fluid, tense, and pulsatile. A his- 
tory of pain down one leg is said to be diagnostic of the side af- 
fected, and the majority of these signs ought to arouse suspicions 
of extra-uterine pregnancy. 

After Rupture. — When called to a woman of child-bearing age, 
presenting a history of sudden collapse, acute anaemia, subnormal 
temperature, and clammy skin, the first thought should be of 
internal hemorrhage due to ruptured tubal pregnancy, whether 
impregnation is or is not probable. It is better to err upon the 
safe side and act accordingly, for post-mortem diagnoses are not 
flattering to one's self-esteem. 

Abdominal Gestation. — In the very rare cases of abdominal 
gestation, there should be a clinical history of irregular pregnancy ; 
the fetal parts and movements ought to be distinct, as if just 
under the surface, heart sounds close to the ear, and ballottement 
probable. 



EXTRA-UTERINE PREGNANCY. 113 

Differential Diagnosis. — Extra-uterine pregnancy should be 
excluded, if possible, from ovarian abscess and cysts, intraliga- 
mentous cysts, hydro-, pyo-, and haematosalpinx, and retroverted 
or gravid uterus. 

Prognosis. — Two-thirds of the patients die without surgical 
treatment ; the others recover from the immediate accident, but 
live confirmed invalids, liable to serious complications from in- 
testinal obstruction, ulceration, septic infection, and hemorrhage. 
The mortality after abdominal section is about five per cent. 

Treatment. — It cannot be stated too emphatically that from 
the moment when ectopic gestation is recognized or even sus- 
pected, the patient should be entrusted to the care of a qualified 
laparotomist, upon whom all responsibility of further management 
should be laid. Temporizing by the general practitioner is trifling 
with life, because it is never possible to know when the gestation 
sac will burst and initiate a fatal hemorrhage. As soon, then, 
as the diagnosis is made, the woman should be removed to a hos- 
pital, if practicable, for surgical treatment. When time permits 
this is altogether the wisest course to pursue, because the patient's 
chances for successful operation in a dwelling and by the physician 
unused to abdominal surgery are very small. 

After Rupture. — Inasmuch as the woman's only hope is in an 
abdominal section, the general practitioner, though a skilled sur- 
geon is unobtainable, should not shrink from the responsibility of 
operating, choosing the abdominal route rather than the vaginal 
because more easy. Sterilize the abdomen as thoroughly as time 
permits with green soap, bichloride, and alcohol, preceding the 
operation by an enema of normal salt solution (one teaspoonful to 
the quart), giving one or two pints or as much as the bowel will 
retain. After opening the abdomen as quickly as possible (see 
Caesarean section, page 279), lose no time in attempting to clear 
away free blood from the cavity, but pass the hand down into the 
pelvis, upon that side which previous history and vaginal exami- 
nation have shown to be affected, clamp the tube as closely to the 
uterus as practicable and also outside the rent, remove the tube, 
ovary, and gestation sac, and suture the cut edge of broad liga- 
ment with lock-stitch of catgut. Clear out free blood, coagula, 
and possibly the foetus from the abdominal cavity with the hands ; 



114 THE PRINCIPLES OF OBSTETRICS. 

quickly irrigate with saline solution, leaving several quarts to be 
afterward absorbed by the depleted vessels, and close the abdomen 
in the usual manner. 

During the operation have an assistant, if much blood has 
been previously lost, inject normal salt solution under the breasts 
or in the subaxillary space, and use hypodermics of strychnine, 
brandy, etc., freely. If the technique has been aseptic, a small 
amount of free blood can be left remaining in the abdominal 
cavity where it is readily absorbed, and the shorter the operation 
the better the chances for ultimate recovery. The Trendelen- 
burg position is useful in freeing to some extent the pelvic cavity 
from blood, which then gravitates toward the diaphragm where 
it is quickly absorbed. Generous stimulation is ordinarily re- 
quired for twenty-four hours after the operation, and the assist- 
ance of a trained nurse is almost essential. 

For technique of operations for interstitial, ovarian, and ad- 
vanced pregnancy, more extensive treatises upon obstetric sur- 
gery should be consulted. 



CHAPTER VI. 

DISEASES OF FCETUS AND APPENDAGES. 

CHORION, CYSTIC DEGENERATION OF VILLI. (VESICU- 
LAR MOLE, HYDATIDIFORM MOLE.) 

The only important disease of the chorion is hypertrophy and 
cystic degeneration of its villi. These become distended by a 
clear fluid from the size of a grain of wheat to a grape or even 




FIG. 37.— Vesicular Mole and Hydramnion ; Hydatids of the Funis. (Schaeffer.) 

a hen's egg, hanging in clusters by long slender pedicles to each 
other and the chorion, and form a mass which when expelled may 
be as large as the adult head and weigh several pounds. Since 

115 



116 THE PRINCIPLES OF OBSTETRICS. 

the vesicles are derived from the chorion, the disease belongs to 
early gestation or before its fourth month. It is characterized by 
rapid growth, unusual distention of the uterus, excessive hemor- 
rhage, and premature expulsion of the ovum covered by small 
translucent cysts. The entire chorion is generally affected, and 
exceptionally the placenta, the foetus ordinarily being atrophied or 
absorbed. 

The disease is most common in multiparas, recurring some- 
times in the same woman, and new cysts may be expelled months 
or years after impregnation. Fragments of the chief mass retained 
after its injection may become septic and general infection follow; 
exceptionally the cystic villi perforate the deciduse and uterine 
walls, causing rupture of the uterus and fatal hemorrhage. The 
disorder is, however, very rare. 

Under the old nomenclature such a degenerated ovum was 
called a " vesicular mole '* ; if derived from fragments of the prod- 
uct of conception, a "false mole " ; if merely coagulated blood or 
a cast of uterine mucous membrane, an " hydatidif orm mole," 
because supposed to be caused by true hydatids, like those found 
in the liver and other organs. 

Clinical History and Diagnosis. — Discharge of bloody serum 
resembling currant juice at any time during the first weeks of 
pregnane}-, rapid enlargement of the uterus toward the third 
month, and failure to detect the foetus by palpation would be sug- 
gestive of cystic degeneration of the chorion, appearance of grape- 
like cysts confirming the diagnosis. Occasional symptoms are 
either sudden distention of the gravid uterus, nausea and vomit- 
ing with dyspnoea from pressure, or the disease does not progress 
beyond development of cysts, the ovum being retained for months 
in utero, which is unnaturally small for the length of pregnancy. 

Etiology. — Little is definitely known of the cause of the de- 
generation, but according to Virchow it is a true myxoma of the 
chorion. 

Prognosis. — Maternal mortality is from ten to fifteen per cent 
from hemorrhage, sepsis, and uterine rupture, the foetus almost 
invariably dying and disappearing by absorption, and the cystic 
ovum usually being expelled before the sixth month. 

Treatment. — If diagnosis is certain, immediate removal is 



DISEASES OF FCETUS AND APPENDAGES. 117 

required to prevent hemorrhage and other emergencies ; if flood- 
ing is going on, the tamponade to save further loss of blood and 
hasten expulsion. Profuse bleeding usually accompanies delivery 
of the mass, and therefore the cavity should be manually emptied 
as quickly as possible, followed by curettement, swabbing with 
tincture of iodine, and thorough uterine irrigation with normal 
salt solution. As the uterine walls are ordinarily very thin, all 
these operations should be performed carefully in order not to 
rupture them. 

Syncytial Cancer. — After abortion, hydatidiform mole, and 
delivery at term a very malignant growth may appear at the pla- 
cental site, the precise histological structures from which it arises 




Fio. 38. — Case of Twin Labor with Unilateral Vesicular Mole, which Became Malignant 
Post Partum. (Schaeffer.) 

being in dispute. The weight of authority seems to favor the 
theory that it originates in the cells of the chorion, either as a 
sarcoma or carcinoma, the latter being more common. Various 
names have been given to the disease, depending upon whether its 
origin is maternal or fetal; if from decidual cells, "deciduoma 
sarcoma," "deciduoma malignum"; if from the syncytium (epi- 
thelial cells of the placental villi), "carcinoma syncytiale," "syn- 
cytial cancer." 

Clinical History. — Soon after a miscarriage or labor at term 
repeated hemorrhages occur from the placental site, which exami- 
nation shows to be very vascular and the basal uterine surface 
pulpy and necrotic. Fragments of mucous tissue removed by 



118 



THE rillXCIPLES OF OBSTETRICS. 



the curette appear malignant under the microscope ; extension of 
the growth is rapid, and death follows in from three to six months, 




Fig. 39.— Syncytial Cancer; Perforation of Uterus by Villi. {Am. Jour n. of Obst.') 

general maternal infection (metastases) being early and wide- 
spread. 

Treatment. — Complete hysterectomy is imperative. 

AMNION AND LIQUOR AMNII. 

Oligohydramnios. — The quantity of amniotic fluid varies nat- 
urally from one to two pints, but occasionally is much less, the 
condition being then called oligohydramnios. Friction by the 



DISEASES OF FCETUS AXD APPENDAGES. 119 

foetus against the amniotic sac and adhesive bands, formed between 
it and the sac walls, results in many deformities of the embryo, 
among which are intra-uterine amputations, harelip, cleft palate, 
spina bifida, and club-foot. 

Hydramnios or Polyhydramnios. — Excess of amniotic fluid 
of over four pints may be considered pathological, and is called 
hydramnios. Increase is ordinarily gradual and may amount at 
term to several quarts, but exceptionally the accumulation, as 
the result of acute amniitis, is rapid, resulting in grave pressure 
symptoms. Hydramnios is much more frequent in multiparas, 
and to some extent physiological in multiple pregnancies, when 
there is often an unequal amount of fluid in the separate mem- 
branes with resultant fetal deformities. 

Etiology — The cause is either an oversecretion of amniotic fluid 
or defective absorption of the same, reasons for the latter being 
still unsettled. 

Oversecretion is due to the mother from general dropsy; (2) 
to foetus from too great renal and cutaneous excretion, or any 
condition which increases blood pressure in the funis (tumors of 
the placenta, fetal heart disease, and cirrhotic liver), amniitis, 
causing effusion like inflammation of any serous membrane, and 
injuries; and (3) to both mother and foetus combined, from 
syphilis in the majority of cases. 

Diagnosis. — The most common symptoms of hydramnios are 
excessive size and tension of the uterine tumor, great movability 
of the foetus, and early pressure symptoms, which are distressing 
in acute hydramnios, fortunately a rare variety. In pregnancy 
with ascites the contour of the uterus can usually be mapped out 
and there is dulness in the flanks ; in pregnancy with ovarian 
and ligamentous cyst there are two tumors of different size and 
shape, but in simple hydramnios only one ; in twin gestation the 
uterus is hard and double heart sounds and movements can be 
differentiated. Diagnosis has been made by exploratory puncture 
of the uterus through the abdominal walls, an apparently harm- 
less operation. 

Treatment. — If distention is extreme, the fluid may be evacu- 
ated by passing a catheter through the cervix high up into the 
cavity, and allowing the water to flow out gradually, the objec- 



120 THE PRINCIPLES OF OBSTETRICS. 

tion to this method being that it necessarily causes premature 
birth of the foetus and, when not viable, its death. In hydramnios 
at term, when the sac is ruptured, the cervix should be plugged 
by the hand, to prevent a sudden gush of water from washing out 
the cord, or causing fainting from rapid loss of abdominal press- 
ure. Flooding after delivery is liable from paralysis of the uterus, 
due to distention, or syncope from failure of the right heart, and 
is prevented by firm bandaging of the abdomen. 

DECIDUjE. 

Hydrorrhoea Gravidarum. — The mucous membrane of the 
gravid uterus is liable to diseases similar to those of the unim- 
pregnated organ. The most important, obstetrically, is catarrhal 
endometritis, because as a result of the inflammatory process fluid 
accumulates, to the amount of a pint or more, between the 
chorion and reflexa, which is less often involved than the vera, giv- 
ing rise to a condition called hydrorrhoea gravidarum. It belongs 
to the last weeks of gestation, and is clinically interesting because 
the fluid passes away at any time of the day or night, either in 
continual dribble or successive jets, the patient naturally receiving 
the impression that the " waters " have broken and labor is pres- 
ent, though generally it is not. Owing to resecretion of the fluid 
and retention within adhesions formed, as a result of the inflam- 
mation, between the deciduae or on account of obstruction of the 
cervix, the discharge may be repeated several times before true 
labor. 

Diagnosis — Hydrorrhoea gravidarum is distinguished from the 
evacuation of true liquor amnii by the fact that the latter occurs 
but once and is followed by labor. 

Treatment. — If the quantity of fluid is large, premature deliv- 
ery may be required for the excessive distention, or spontaneously 
follow the sudden discharge of a considerable amount ; otherwise 
the disease is of no special obstetric importance. 

Specific Endometritis — A syphilitic, gonorrhoeal, or septic 
endometritis, which existed before impregnation, may continue 
after it, resulting during the later months in exaggeration of the 
hyperplasia of uterine mucous membrane, which is natural to 



DISEASES OF FCETUS AXD APPENDAGES. 121 

pregnancy, with associated decidual hemorrhages and cystic de- 
generations. Premature delivery is the rule with all these patho- 
logical affections of the deciduse. 

PLACENTA. 

Anomalies of Shape. — Many irregularities are found in the 
shape of the placenta; placenta membranacea, when broad and 
thin with persistence of villi over the entire surface of the chorion, 
usually adherent after delivery of the child ; placenta previa, when 
developed in the lower uterine segment or about the outlet ; pla- 
centa succenturiata, an accessory lobe from independent cotyle- 
dons, usually single, sometimes double. 

Placentitis. — Inflammation of the placenta, either of the en- 
tire structure or more rarely of portions, is due to endometritis 
(present before impregnation or acquired afterward), syphilis, or 
acute sepsis, and results in fibroid degeneration or decidual dis- 
ease. It is very rare. 

Syphilis of the Placenta. — The placenta is larger and paler 
than natural, with yellowish nodules scattered about within its sub- 
stance and upon the surfaces. If of paternal origin, the fetal side 
is affected ; if of maternal, the decidual, gummata being present 
in the tertiary stage. If the mother is infected during insemina- 
tion at the same time as the ovum, the maternal placental surface 
will be syphilitic; if syphilitic before or soon after conception, 
the placenta will be infected in fifty per cent of cases ; if not 
syphilitic until after the seventh month, the foetus and placenta 
are healthy. Infection of the mother during delivery is doubtful. 
The disease is distinctly injurious or even fatal to the foetus. 

Apoplexy of Placenta. — Hemorrhages, when early in gestation, 
appear upon the fetal surface; when later, upon the maternal. 
The causes are placentitis, general infectious diseases of the 
mother, and injuries. Small extravasations do little injury, be- 
coming afterward partially organized, fatty, or calcareous ; large 
hemorrhages cause death of the foetus and abortion. 

Infarctions. — Dense white or yellowish masses of degenerated 
villi are often found scattered about in the placenta, but unless 
numerous enough to destroy its nutritive function they are of no 
especial importance. 



122 THE PRINCIPLES OF OBSTETRICS. 



UMBILICAL CORD. 

Variations in Length. — These are commonly important only as 
they affect delivery. If too short, expulsion of the child may be 
prevented, and traction upon the placenta cause its premature de- 
tachment. Its symptoms are: pitting of the fundus during and 
with each contraction, the contraction itself being more painful 
than usual ; retraction of the child in the interval between pains, 
and delay in birth without evident explanation. 

Treatment. — If due to coiling about the neck or other recogniz- 
able cause, cut between two haemostats or ligatures ; if the cord 
cannot be reached, the only recourse is forceps extraction. (See 
chapter on Conduct of Labor.) 

If it is too long, prolapse of a portion is liable to occur when 
liquor amnii is discharged, and so are coiling about the child, tor- 
sion, and knots. Prolapse and coiling of the cord as obstructions 
to delivery will be discussed under Dystocia. Torsion may inter- 
fere with its circulation, but is usually found only after death, and 
knots are ordinarily curiosities rather than important complica- 
tions. 

Anomalies in Situation. — The cord may be attached to the 
edges of the placenta (battledore placenta), or terminate within 
the membranes from which its vessels pass to the placenta (in- 
sertio velamentosa) . These irregularities are serious only when 
they cause intra-uterine hemorrhage from rupture of umbilical 
vessels. 

FCETUS. 

Infectious Diseases. — The foetus is liable to any infectious dis- 
ease of the mother, particularly scarlatina, rubeola, variola, syph- 
ilis, septic infection, and possibly tuberculosis, most of which have 
been already considered. 

Death in Utero. — In the early months of gestation diagnosis of 
fetal death is ordinarily impossible, and in the later it can be 
decided only after repeated examinations. The usual symptoms 
immediately or soon after death are absence of fetal heart sounds 
and movements, looseness and crepitation of the cranial bones, 
general malaise in the mother, weight and coldness in the abdo- 



DISEASES OF FCETUS AND APPENDAGES. 123 

men, retrograde changes in the breasts and arrest of secretion of 
milk ; the uterus is flabby and smaller than natural, and there are 
probably fetid vaginal discharges. An invariable sign of fetal 
death is the presence of acetonuria in the mother, indicated by 
the appearance of a violet color in a sample of her urine, to which 
has been added a solution of fuchsin, i to 2,000. When the foetus 
is living the temperature of the cervix is one or two degrees 
higher than that of the vagina ; but if both are equal the foetus is 
probably dead. 

Etiology. — As has already been mentioned, the causes of fetal 
death are many and varied. Habitual death in utero is, in a 
majority of cases, due to syphilis in the parents, its most valuable 
sign being found post mortem in a peculiar yellow line (osteochon- 
dritis) between the diaphysis and epiphysis of the lower end of 
the femur and other long bones. There is also increase in weight 
of the spleen and liver, in the latter enlargement often to one- 
twelfth or one-eighth of the entire body weight. 

Treatment. — When it is certain that the foetus is dead, the 
uterus should be emptied at once, either according to the method 
directed for abortion or if at term in the usual manner. 



PART IV. 
MECHANISM OF LABOR 



CHAPTER I. 

THE FACTORS CONCERNED. 

A thorough understanding of the essentials of the mechanism 
of labor must precede its intelligent management. By mechan- 
ism is implied the apparatus by which childbirth is accomplished ; 
the shape of the child as it affects delivery, the agents by which 
the work is performed, and the fitness of the birth canal for the 
process. The factors of labors are: I. The Powers. II. The 
Passages. III. The Passengers. 

I. THE POWERS. 

Childbirth is the work principally of contractions of the uterus, 



w 



holly involuntary, assisted by those of the abdominal muscles, 
partly spontaneous, partly reflex, and to some extent by the struc- 
tures of the pelvic floor. In theory, uterine contractions are peri- 
staltic waves of motion starting at the fundus and passing down- 
ward to the cervix, but practically the entire organ acts as a 
single muscle, steadied in the abdomen by the influence of the 
muscular fibres of the round and broad ligaments. We have seen 
that these contractions are present during the entire period of 
gestation, ordinarily without the knowledge of the woman and at 
irregular times, completing their purpose at the crisis of delivery. 
Parturition is universally called labor, because the product of the 
greatest physical and mental effort ; and since in civilized women 
expulsive contractions always cause pain, the words "contrac- 
tions " and "pains " are used interchangeably. 

Labor is divided into three stages : the first or dilating extends 
from its beginning to complete opening of the uterine outlet ; the 
second or expulsive, from the end of the first stage to the birth of 
the entire child ; and the third or placental, from the end of the sec- 
ond to full retraction of the empty uterus. During the early part 

127 



128 



THE PlilXCIPLES OF OBSTETRICS. 



of the first stage pains last only a few seconds, with half-hour in- 
tervals of rest, and suffering is moderate; but toward its close 
they grow in frequency and severity, are cutting and grinding in 
character, and more and more distressing. At the beginning of 
the second stage the "bag of waters " usually ruptures, the liquor 




Fig. 40.— First Stage of Labor ; Frozen Section. (Barbour.) 



amnii is discharged, and pains are now expulsive. The contractile 
power of the birth canal is working at its highest tension, aided 
by straining of the abdominal muscles and bearing-down, the 
throes of travail terminating suddenly in extrusion of the child 
from the vulva. After a short interval of rest the third stage 



THE FACTORS CONCERNED. 



129 



commences with delivery of the placenta and secundines, ending 
in complete retraction of the uterus. 

The mechanism of expulsion in the second stage is as follows : 
During contractions the uterus is divided into an upper or contrac- 
tile segment and lower or dilating segment by a prominent ridge, 
the contraction ring (Bandl's ring), situated just above the sym- 




FlG. 41.— Second Stage of Labor ; Frozen Section. (Barbour.) 



physis, where it is distinct in obstructed labors. The upper ute- 
rine segment, assisted by the abdominal muscles, supplies the 
power that drives the child through the rest of the canal, exerting 
an intra-uterine pressure variously estimated at from fifteen to 
sixty-five pounds. Dilatation of the lower uterine segment results 
from a number of causes: from the action of the longitudinal 
9 



130 



THE PRINCIPLES OF OBSTETRICS. 



muscles of the upper segment, which pull the circular muscles of 
the cervix, to which they are attached, over the presenting part; 
from paralysis of the cervical sphincter, due to continuous pulling 
and pushing; partly from the force of gravity residing in the 
weight of the child ; and, finally, from softening of the cervix 
caused by vascular congestion. If the membranes are unrup- 
tured, the immediate dilating force is the liquor amnii, under whose 
pressure, like that of a soft, smooth cone, the mouth of the uterus 
opens; if, as often happens, the membranes are prematurely 




Fig. 42. — Third Stage of Labor ; Frozen Section. (Barbour.) 



broken, the presenting part of the child must act as the dilator, a 
work for which the hard, unyielding head or breech is poorly 
adapted. 

The placental or third stage is separable into three acts, differ- 
ing in character but continuous in time: I. Detachment of pla- 
centa; II. Expulsion; and III. Retraction of the uterus. I. For 
the first, three explanations are given : ( 1 ) Contraction of the pla- 
cental site; (2) the uterus pushes the placenta off from its wall; 
and (3) hemorrhage takes place behind the placenta, that is, be- 



THE FACTORS COXCEFXED. 131 

tween the uterus and placenta, which tears it off from its uterine 
base. The first of these is more generally accepted. II. Con- 
tractions of the upper segment drive the placenta into the non- 
contractile portion of the canal — cervix and vagina — where it may 
remain for some time because of paralysis of the canal from long 
distention. Usually some assistance is needed to extract the pla- 
centa from the vagina, out of which it escapes either edgewise or like 
an inverted umbrella, dragging the membranes from the uterus, 
to which they are naturally adherent, behind itself. III. After 
delivery the upper uterine segment promptly retracts, the mech- 
anism consisting of a rearrangement of its muscular fibres with 
thickening and shortening of the fibres themselves ; but the lower 
segment remains flaccid for several hours. 

The second or accessory agent in childbirth is the power of the 
abdominal muscles, which during the expulsive stage of labor 
strengthen uterine contractions by decreasing intra-abdominal 
space, and is both spontaneous and reflex. 

The third agent is the resistance of the structures of the pelvic 
floor, which impel the opposing portion of the child or placenta 
through the external outlet, and, like the action of the abdominal 
forces, is partly voluntary and partly irresistible. 

II. THE PASSAGES. 

The obstetric pelvis and female sexual organs have been pre- 
sented in Part I., Chapters I. to III. 

III. THE PASSENGERS. 

When fully developed, the foetus is from eighteen to twenty 
inches long and weighs from seven to eight pounds, males being 
usually one-half pound heavier than females. These dimensions 
vary according to heredity, race, and environment, weight in some 
portions of the United States averaging a. pound more than" that 
given. Children born weighing less than five pounds are reared 
with difficulty, and those exceeding nine pounds are frequently 
still-born, owing to injuries received at delivery. 

The fetal head, being less compressible than the softer trunk, 



132 



THE PRIXCIPLES OF OBSTETRICS. 



offers greater hindrances to birth, and therefore is of more obstet- 
ric importance. The skull is oval or egg-shaped, the chin corre- 
sponding to the smaller end, occiput to the larger, the greatest 
width being at the parietal eminences, and is divided for descrip- 
tive purposes into the cranial vault and cranial base. The former 
is composed of the frontal and parietal bones, together with the 
squamous portion of the occiput, and is elastic because its several 
components are united by fibrous tissue rather than by bone, these 
membranous interspaces or sutures providing for reduction of the 




C 

Fig. 43 .— Fetal Skull ; Profile. 



head during delivery. The cranial base includes the bones of the 
face and lower portion of the skull, the entire ethmoid and sphe- 
noids, basilar portion of the occiput, and petrous part of the tem- 
porals. Since the important structures of the face and delicate 
tissues of the brain require special protection against the violence 
of labor, this region is rigid and incompressible. 

Sutures. — The sagittal (interparietal) suture extends from the 
apex of the occiput between the parietals, merging into the frontal, 
which connects the as yet ununited frontal bone, and intersect- 
ing the coronal (fronto-parietal) as it crosses the arch of the cra- 
nium between the parietals and frontals. Between the occiput 



THE FACTORS COXCERXED. 



183 



and parietals is the lambdoid suture, named for its resemblance 
to the Greek letter /, lambda. 

Fontanels. — The word is derived from the Latin fontanella, 
a little fountain, because of a fancy that the pulsations of the 
underlying cranial arteries resemble the rising and falling of 
water in a spring. The fontanels are membranous spaces at the 
points of union between the parietals and their adjacent bones, 
and are six in number, of which two only are of obstetric interest. 




Fig. 



-Fetal Skull ; Vertex. 



The anterior (greater or bregma) is diamond-shaped, with its long 
angle pointing to the frontals and its shorter angle to the parietals, 
situated at the junction of the sagittal and coronal sutures, and 
about one inch long. It does not close until after the second year 
of life, and is recognized by its shape, size, and four sutures that 
enter it. The posterior (lesser) fontanel is ordinarily a mere de- 
pression, triangular in shape, at the junction of the sagittal and 
lambdoid sutures, closing three or four months after birth. Three 
lines of sutures pass into it, and behind is the squamous portion 
of the occiput. 



134 THE PRINCIPLES OF OBSTETRICS. 

The other four fontanels are at the lower edge of the parietals, 
two on each side, of no special value. 

The head has five protuberances or centres of ossification, 
which serve as obstetric landmarks : one occipital, on the occiput, 
about one inch behind the posterior fontanel ; two parietal and 
two frontal, one for each bone. 

In obstetric nomenclature, the " vertex " is the space outlined 
between the fontanels and parietal protuberances; "occiput," the 
part of the skull behind the posterior fontanel; and "sinciput" 
or forehead, in front of the anterior fontanel. 



DIAMETERS OF THE FETAL HEAD AND THEIR APPROXI- 
MATE AVERAGE LENGTH. 

Occipitomental : From the point of the chin to the superior angle of the 

occiput — 5 inches (14 cm.). 
Occipitofrontal : From the centre of the forehead to a point on the median 

line of the occiput a little above its protuberance — 4*4 inches (11. 4 

cm.). 
Biparietal : From one parietal protuberance to the other — 3^ inches (8.8 

cm.). 
Cervico-bregmatic (trachelo-bregmatic) : From the posterior angle of the 

anterior fontanel vertically to the anterior margin of the foramen 

magnum — 2>% inches (8.8 cm.). 
Fronto-mental : From the top of the forehead to the end of the chin — 2> l A 

inches (8.8 cm.). 
Bitemporal : From the lowest extremities of the coronal suture — 3^ inches 

(8.2 cm.). 
Suboccipito-bregmatic : From the junction of the neck and occiput to the 

centre of the anterior fontanel — 3^ inches (9.5 cm.). 

For purposes of comparison the internal pelvic diameters are 
here recapitulated : 

Brim, Antero-posterior : From the centre of the promontory of the sacrum 
to the top of the symphysis pubis — 4 inches (10. 1 cm.). 

Brim, Transverse: From side to side of the widest part — 4 inches (10. 1 
cm.). 

Brim, Oblique : From the sacro-iliac synchondrosis to the pectineal emi- 
nence — 4^ to 5 inches (12.7 cm.). 

Outlet, Antero-posterior : From tip of coccyx to lower end of symphysis 
pubis — \y z to 5 inches (12.7 cm.). 



THE FACTORS CONCERNED. 135 

Outlet, Transverse : From one tuberosity of the ischium to the other — 4 

inches (10. 1 cm.). 
Cavity, Antero-posterior : From centre of symphysis pubis to hollow of 

sacrum— 5 inches (12.7 cm.). 
Cavity, Transverse: At the same level as the antero-posterior — 5 inches 

(12.7 cm.). 

Articulations between the Head and Spine. — The occipito- 
atlantoid joint admits simply of flexion and extension, the atlanto- 
axial of rotation only, not safely through an angle of more than 
ninety degrees beyond a point where the chin is in line with the 
shoulders, the other cervical vertebrae combining with these mo- 
tions. Antero-posterior flexion is checked by contact of the chin 
with the breast, and extension when the occiput rests upon the 
back of the neck. 

Diameters of the Fetal Body. — The transverse diameters of 
the shoulders and hips are always relatively larger than the antero- 
posterior. The shoulders enter the pelvis in a position either at 
right angles to the spine, or one is lower than the other ; the lat- 
ter is most usual. The hips are too rigid to permit of much 
change, and the trunk is too soft and compressible for its diam 
ters to be regarded. 

Definitions. — The following definitions of terms constantly 
used in obstetrics should be memorized : Attitude is the arrange- 
ment of the fetal parts relative to each other rather than to the 
mother. Ordinarily the foetus in utero is pressed into a compact 
mass, the head being flexed upon the breast, the arms folded across 
the chest, the thighs resting upon the abdomen, and the legs 
against the thighs. Presentation is the part of the foetus which 
presents itself to examination in the centre of the superior strait. 
The various presentations are : cephalic, when the foetus enters 
the brim head first, subdivided into vertex, brow, and face, accord- 
ing to the several portions lowest in the cervical outlet ; pelvic, 
subdivided into breech and feet; and transverse, or hip, trunk, 
and shoulder presentations. Position is the relation which the 
dorsum of the child bears to the several quadrants of the pelvis. 
Each presentation may be in one of four positions : anterior or 
posterior, right (dextra) or left. 

Classification of Presentations and Positions. — Presentations 



136 



THE PRINCIPLES OF OBSTETRICS. 



are classified into longitudinal, when the long axis of the foetus 
corresponds to that of the mother, and oblique, when there is a 
considerable angle between the two, the second variety including 
all cases in which any part of the foetus other than head or 
breech is at the pelvic brim. They are also normal and abnormal, 
natural and unnatural, the only normal presentation being ceph- 
alic, which occurs in about ninety-seven per cent of all cases, 
about ninety-five per cent of these being vertex, with all others 
considered abnormal. Natural presentations are those which are 





FIG. 45. — Casts of Full-Term Foetuses; Illustrating Normal Attitude in Utero. 

(Barbour.) 

expected to terminate by natural or unaided labor, such as those 
of the vertex, face, and breech ; unnatural, when artificial help is 
required, as in brow and transverse cases. 

Positions are classified according to the relation of the most 
prominent point on the dorsal side of the presenting part, except- 
ing in face presentations when the chin is selected, to the acetab- 
ula or sacro-iliac synchondroses of the mother. Thus each pres- 
entation has four positions, beginning on the left, numbered in 
the order named, and conveniently represented by abbreviations : 
occiput left anterior, O. L. A.; occiput right anterior, O. D. (dex- 
tra) A.; occiput right posterior, O. D. P.; and occiput left pos- 



TEE FACTORS CONCERNED. 137 

terior, 0. L. P.; chin (mentum) left anterior, M. L. A., etc.; 
sacrum left anterior, S. L. A., etc. ; scapula left anterior, Sc. L. 
A., etc. 

Frequency of Presentations and Positions. — The most frequent 
presentation is the cephalic, because this position in the uterus is 
most comfortable for the foetus and allows most room for its de- 
velopment, the relatively spacious fundus permitting free use and 





Fig. 46.-— Cast of Full Term Foetus and Membranes, Showing Attitude in Uterus. 

(Barbour.) 

growth of its lower extremities. Seventy per cent of all vertex 
presentations are L. O. A.; thirty per cent, R. O. P.; O. D.*A. 
and O. L. P. presentations occur in about one per cent. O. D. A. 
presentations are usually O. D. P. at engagement, but turn forward 
on the pelvic floor and appear at the outlet as O. D. A. The fre- 
quency of O. L. A. and O. D. P. presentations is due to the fact 
(1) that the left oblique diameter is narrowed by the presence of 
the rectum, which compels the long axis of the head to assume 



138 



THE PRINCIPLES OF OBSTETRICS. 



the right oblique diameter; and (2) the anterior surface of the 
child adapts itself to the projecting lumbar vertebrae, causing the 
dorsum to turn forward and the foetus as a whole to tilt toward 






Fig. 47.— Cephalic Presentations. (From an Old German Atlas.) 

the right, owing to the normal right latero-version of the gravid 
uterus. If the dorsum is toward the right, the chin is pushed for- 
ward by the rectum and sigmoid flexure, making O. D. P. the sec- 
ond most frequent position. 



THE FACTOJRS COXCEEXEB. 139 

Mechanism of Labor in Vertex Presentations. —Mechanism 
of labor in vertex presentations is adopted as typical of all others, 
and divided into the following stages : Flexion, descent, rotation, 
extension, and restitution. 

L. O. A. I. Flexion is already present to some extent as the 
natural attitude of the foetus in utero, and is explained by the fact 
that the head is not attached to the spine at the centre of its base, 
but the occipital radius is shorter than the frontal. As the head 
impinges upon the brim at engagement, the longer or frontal end 
of the lever is caught first by it and held back, while the shorter 
or occipital descends into the cavity, flexing the head upon the 
body. 

II. Descent. The head enters the inlet by the smallest diam- 
eter (the suboccipito-bregmatic, three and three-quarter inches), 
the occiput first, directed to the acetabulum, and the forehead to 
the sacro-iliac synchondrosis. Progress follows by alternate acts 
of descent and retreat, the former under the power of uterine con- 
tractions, the latter from the elasticity of the pelvic interior, the 
head meantime being moulded to fit the cavity until it reaches the 
pelvic floor. 

III. Rotation. As the longest diameter of the inlet is the 
oblique but the antero-posterior of the outlet, the head must ro- 
tate while passing from the upper to the lower. Change of direc- 
tion is caused by motion of the occiput along the pelvic floor and 
anterior inclined plane, which turns it forward, downward, and 
toward the median line, the forehead at the same time, by press- 
ure of the posterior inclined plane, turning backward, downward, 
and to the hollow of the sacrum. 

IV. Extension. Descent continues until the occiput is ar- 
rested by the posterior surface of the symphysis and arch of the 
pubis ; but the forehead under pressure of the driving power moves 
along the pelvic floor, the head now changing its attitude from 
flexion to extension. The face and chin pass the coccyx, are 
pushed along the perineum by the resistance of its muscles, and, 
finally, the head as a unit rotates under the pubic arch, upon 
which the occiput turns like the hub of a wheel upon its axle, 
emerging from the outlet in extreme extension. 

V. Restitution. After a short period of rest, the head reas- 



140 TEE PRINCIPLES OF OBSTETRICS. 

sumes its natural attitude toward the shoulders, the occiput turning 
to the mother's left thigh and completing the stage of restitution. 
The shoulders follow the same motions during descent as those of 
the head ; the right, having entered the pelvis in the opposite diam- 
eter from that of the latter, nearest to the pubis, turns forward, is 
caught by the pubic arch, and the left is expelled from the outlet 
in a similar manner to that of the forehead. The rest of the body 
follows without any special mechanism. 

O. D. A. The mechanism for this position is the same as 
that of O. L. A., except that the direction of rotation is reversed; 
the occiput turns forward upon the right anterior inclined plane, 
and forehead backward upon the left posterior inclined plane, 
while in restitution the occiput turns toward the mother's right 
thigh. 

O. D. P. The stages of flexion and descent are similar to 
those of the anterior positions. The occiput rotates into the an- 
terior position, in a large proportion of cases, under a similar mech- 
anism ; in a small number the occiput remains posterior and the 
forehead turns to the pubes. In cases of posterior rotation flexion 
continues until the occiput escapes from the perineum, when it 
immediately falls backward to the anus in extension, and the fore- 
head, face, and chin pass upward under the pubes. In restitution 
the occiput turns to the right thigh, or the side corresponding to 
the original engagement. 

O. L. P. The mechanism is similar to that of O. D. P., 
except that rotation and restitution are in opposite directions 
from it. 

In order not to confuse the beginner with too many details, 
the mechanism of unnatural presentations will be given under 
their appropriate headings in the chapter on Dystocia. 

DIAGNOSIS OF PRESENTATION AND POSITION BY ABDOM- 
INAL AND VAGINAL EXAMINATION. 

Presentation. — Presentation of the foetus is usually unaltered 
during the last weeks of gestation, but its position within that 
time may and does change frequently. Examination for position, 
therefore, had better be postponed until engagement — that is, 



THE FACTORS COXCERXED. Ill 

until the presenting part has descended far enough into the supe- 
rior strait to check any further voluntary changes. 

The diagnosis of presentation is made by combined abdominal 
and vaginal examination, using for the former the methods of 
inspection, palpation, and auscultation. Inspection is useful only 
as the appearance of the uterine tumor suggests multiple preg- 
nancy or transverse presentations. Palpation of the abdomen 
should be made in the intervals between contractions, the patient 
being in bed, dressed simply in her night-clothes, and during ex- 
amination lying squarely upon her back with the abdomen uncov- 
ered. The finger tips merely are used, all pressure being slow, 
gentle, and painless, and anxiety on the part of the woman di- 
verted in every way possible. It should be remembered that by 
far the larger number of presentations are cephalic ; therefore the 
fingers ordinarily will recognize behind the symphysis the hard 
round head, noting upon which side it is most distinct. If well 
flexed, the forehead is the more easily reached ; if partly extended, 
there is little difference between it and the occiput ; and if well 
extended, the latter is definite. At the fundus the head is dis- 
tinguished from the breech by its greater size and mobility, the 
shape is round rather than tapering, and possibly the sulcus cor- 
responding to the neck may be felt. Generally the breech can be 
recognized at the fundus by contrast with the peculiarities of the 
head just given, and obviously if the head is at the symphysis the 
breech must be at the opposite uterine extremity. In transverse 
presentations the body of the child is felt crosswise in the abdomen. 

In palpating for position, the hands should be placed along 
the sides of the uterus and deep pressure made with the palms in 
a series of rubbing, gliding motions. After a little experience 
the firmer, more resistant dorsum of the foetus is readily distin- 
guished from its softer, elastic anterior surface, and if the ab- 
dominal walls are relaxed and the liquor amnii is limited the more 
prominent lower extremities are somewhat distinct. 

Auscultation of the uterine tumor confirms the diagnosis of 
presentation and position, indicates a lessening of fetal vitality, 
by changes in rate and volume of its heart sounds, and multiple 
fetation. In vertex presentations the strongest heart tone is over 
the back of the child, an inch below and outside of the mother's 



142 THE PRINCIPLES OF OBSTETRICS. 

umbilicus ; in breech presentations, over the back but above the 
umbilicus ; in those of the face, most distinct over that part of the 
uterus which corresponds to the child's face, but below the um- 
bilicus ; in transverse presentations, auscultation is of little diag- 
nostic value. It is generally safe to consider, on account of their 
relative frequency, all positions as-OrL. A., in which the fetal 
heart sounds are loudest in the left lower uterine quadrant, and 
as O. D. P., those loudest in the opposite quadrant, it being im- 
possible to diagnose accurately the other two positions except by 
vaginal examination. (See Fig. 27, page 55.) 

Vaginal examination for presentation and position is better 
made with middle and index fingers together, rather than with the 
index alone, because the middle is nearly an inch longer than the 
other and therefore can reach that much higher into the pelvis. 
The patient should lie upon her left side, and, after the vulva and 
hands have been sterilized, the bedclothes are lifted by the nurse 
or physician's free hand while examination is being made. It is 
more cleanly to pass the fingers, after being well lubricated, into 
the canal by sight rather than by sense of touch, because there is 
less risk of soiling them by contact with the anal region. The 
size and dilatability of the vaginal opening, the position of the 
coccyx, the distance of the promontory, and the condition of the 
rectum are first noticed. The os is recognized by passing the 
finger into and through it, and its peculiarities are studied : length, 
size, character (whether hard or soft), and amount of dilatation. 
Care must be taken not to mistake a very thin cervix for the mem- 
branes, and injure it by attempts to rupture the latter. 

VAGINAL SIGNS OF THE DIFFERENT PRESENTATIONS. 

Vertex. — The finger may recognize the sagittal and frontal 
sutures, small fontanel, or kite-shaped large fontanel with four 
sutures entering it. If the head is well flexed, the posterior fon- 
tanel is lower in the pelvis than the anterior; if somewhat ex- 
tended, both are on a level, and with extreme extension the eye- 
brows may sometimes be felt. The rim of the ear, unless folded 
back upon the head, always points to the occiput, and therefore 
fixes the position. 



THE FACTORS COXCERXED. 143 

Brow. — Extension is extreme, the small fontanel is reached 
with difficulty, and the supraorbital ridges and bridge of the nose 
are well below the brim. The small fontanel is at one end of 
the suture, and the bridge of the nose at the other. 

Face. — The supraorbital ridges are on one side of the pelvis 
and the chin is on the other, diagnosis being established by recog- 
nizing the eyes, the nose between them, and the mouth, within 
which the finger may feel the maxillae and tongue. When the face 
has been long impacted in the canal, the error is sometimes made 
of mistaking it for the breech, the testicles being taken for the 
eyes and the anus for the mouth. A more thorough examination 
should clear away the doubt, the mouth being distinguished by 
the hard gums and often by attempts at suckling upon the finger, 
and the anus by discharge of meconium. 

Breech. — The finger should recognize the spinous processes of 
the sacrum, anal cleft, and genitals, and if the scrotum is much 
swollen from pressure care must be taken not to mistake the tes- 
ticles for the eyes. The finger should be inserted, if possible, 
into the child's anus and feel the end of the coccyx, meconium 
also being present. 

Hand or Foot. — If the membranes are ruptured, the feet or the 
hand may be drawn outside the vulva, and there distinguished by 
sight. If still intact, the following points of differentiation may 
be remembered : The foot is unlike the hand by having malleoli 
and a heel, and the great toe is of equal length with the others ; 
the hand is without a heel, the thumb is shorter than the fingers 
and can be flexed upon them. 

Knee and Elbow. — Either can be recognized through the sense 
of touch by following it to its termination in a hand or foot. 

Transverse Presentations. — It is difficult to make a diagnosis 
of shoulder presentations by vaginal examination, in place of 
which external palpation is better. For hand presentations, the 
classical rule for diagnosing which one of them offers is by direct- 
ing the obstetrician to attempt to " shake hands " with the child, 
when his right hand will grasp most naturally its right, and vice 
versa. While theoretically correct, the method is simply confir- 
matory of the results of external palpation. 

Prognosis of Presentations and Positions. — Generally speak- 



144 THE PRINCIPLES OF OBSTETRICS. 

ing, vertex presentations are most favorable for mother and child, 
depending upon the position for the child alone, O. D. P. being 
more dangerous than O. L. A. Most face presentations require 
artificial assistance, being therefore more hazardous to both, and 
particularly so to the child. The prognosis of brow presentations 
is that of the operation required for delivery ; in breech cases risk 
to the mother, if a primipara, is increased by the probability of lacer- 
ations of the cervix and perineum, being decidedly greater for the 
child through unavoidable delay in delivering the head. Trans- 
verse presentations must always terminate artificially, early podalic 
version in uncomplicated cases being usually easy and safe ; but in 
neglected cases prognosis is uniformly bad for both mother and 
child. 



PART V. 

LABOR AND THE PUER- 
PERIUM. 



10 



CHAPTER I. 
LABOR: ITS PHYSIOLOGY AND PREPARATION. 

Labor is the act of childbirth. It is difficult to frame a defini- 
tion that will include all its varieties, spontaneous or artificial, 
easy or difficult, safe or dangerous. A most comprehensive term 
is therefore selected, descriptive alike of the simplest and most 
complicated performance. Two great classes are recognized: 
normal labor or eutocia (eu-zo/j>? ) good birth), and difficult labor or 
dystocia (dbs-rdxo?, hard birth), either of which is separable into 
many subdivisions. 

Normal labor includes all uncomplicated cases in which the 
vertex presents in anterior positions, when the child is born 
without artificial assistance and birth is completed within the class- 
ical period, safely to both mother and child. 

Difficult labor includes all presentations other than those in 
anterior vertex positions, all emergencies, whether maternal or 
fetal, retarding delivery, besides all requiring obstetric operations. 

Duration of Labor. — The duration of labor evidently depends 
upon two conditions : it is shortened by mutual harmony between 
the three great factors of birth — powers, passages, and passengers 
— and lengthened by the degree of their disproportion. For 
primiparae, in whom the birth canal has its virginal tone, the aver- 
age length of labor is twenty hours, divided into seventeen hours 
for the first stage, two and one-half hours for the second, and one- 
half hour for the third; for multiparas, the average duration is 
twelve hours, the second and third stages being ordinarily shorter 
than in primiparae. Among the laboring class of women, whose 
muscles are developed by hard physical work, labor is usually 
shorter and more energetic than in the wealthier, and may be 
completed in a few moments. 

Etiology of Labor. — The causes of labor are usually given as 

147 



148 THE PRINCIPLES OF OBSTETRICS. 

heredity, or the habit of childbirth at a definite time as a result of 
the great law of evolution ; reflex action of the sympathetic ; satu- 
ration of the maternal blood with carbon dioxide ; progressive ir- 
ritability of uterine muscular fibre, resented finally by its contrac- 
tion ; and increasing distention of the uterine cavity beyond its 
point of toleration. Two explanations are given by Hirst : (i) 
Labor results from the law of periodicity, that is, from influence 
of the menstrual molimina or recurrence of the time for the ab- 
sent menstruation, especially the tenth; and (2) maturity of the 
ovum, degenerative changes taking place in its attachments to the 
uterus, when it is expelled like any foreign body. 

Childbirth is largely a natural process and often finished with- 
out professional aid, but its character depends much more than is 
thought upon locality. Women country born and bred require 
and expect less professional assistance at this time than those 
reared in cities, a more natural life fitting them better for muscu- 
lar work and making them more self-reliant. It is susceptible of 
argument that the superior diet, the more protected home-life, and 
the higher intellectual training of the city tend to greater physical 
development in utero of the child, and therefore to more difficulty 
in its delivery. 

Preparations for Labor. — The professional conduct of labor 
depends for its quality not only upon the technical skill of the 
accoucheur, but also upon the degree of usefulness of the nurse. 
For these two reasons mortality statistics of lying-in hospitals 
are always better than those in private practice. But while pre- 
paratory instruction in obstetrics is acquired in the hospital, it 
must be practised largely in the home. In order to make this 
book useful to those who must work ordinarily without the con- 
veniences and assistants of the public maternity, it should be 
understood that its directions for the management of labor apply 
chiefly to childbirth in the houses of the great middle class of our 
people. 

Parturient women can be placed in one of four classes : Those 
who can have a trained obstetrical nurse ; those who must rely 
upon the half-trained nurse ; those whose only assistant must be 
a well-meaning though ignorant relative ; and, finally, the destitute 
and helpless. The management of normal labor among the sec- 



LABOR: ITS PHYSIOLOGY AND PREPARATION. 149 

ond and third of these classes will be considered first, and dystocia 
afterward. 

Every woman should be encouraged to place herself early in 
gestation under the supervision of her physician, and train herself 
like an athlete by his directions for the supreme day of trial. It 
should be impressed upon her that a skilful nurse is desirable, not 
only for her helpfulness in lessening the pain and tedium of the 
lying-in chamber, but also because she will easily save her wages 
in preventing unnecessary professional expense. Advice may 
properly be given to her regarding selection and preparation of 
the bedroom, the articles that will be needed by the physician for 
delivery, and by the nurse for dressing the child. Finally, the 
symptoms of early labor should be described to her, in order that 
she may know when to send for the physician and nurse. 

Diagnosis of Approaching Labor. — It is accepted without argu- 
ment that the woman under consideration is really pregnant and 
the time for delivery has come, ridiculous and serious mistakes 
having often occurred in these respects. Diagnosis of the begin- 
ning of labor is made from the following symptoms : ( I ) The sen- 
sation of lightening (page 58) or relief from embarrassed breath- 
ing and abdominal distention by descent of the presenting part 
into the pelvis, usually perceived by primiparae about ten days be- 
fore true labor, and by multiparas at any time during the last 
month; (2) recurrent pains of characteristic length and situation, 
following about every half-hour and lasting at first only a few sec- 
onds, which commence suddenly and are located in the small of 
the back or over the symphysis; (3) the show, a bloody mucous 
discharge from the vagina, originating from expulsion of the cer- 
vical mucous plug, stained with blood from rupture of fragile de- 
cidual vessels near the internal os when it begins to open; and (4) 
and most trustworthy, dilatation and effacement (apparent short- 
ening) of the cervical canal, produced by descent of the presenting 
pan into its upper portion. These cervical changes are usually 
progressive and initiative of the first stage of actual labor, though 
occasionally after the external os has opened to a considerable ex- 
tent further uterine action is arrested, and hours or days may in- 
tervene before its renewal. Generally speaking, the shorter the 
neck of the cervix, the sooner labor begins. 



150 THE PRINCIPLES OF OBSTETRICS. 

Management of Normal Labor. — The technique to be described 
represents the principles of aseptic midwifery adapted to the ne- 
cessities of private practice, such as the pecuniary abilities of the 
family, deficiencies of ignorant, self-taught nurses, distrust of the 
laity for innovations in childbirth, etc. It is intended for the gen- 
eral practitioner, not the expert, requires little apparatus or special 
maternity training, and if conscientiously observed results in asep- 
tic parturition. 

List of Articles for Labor and Baby Clothing. — The following 
list of articles, suggested by Hirst, has been carefully revised by 
trained obstetrical nurses and mothers in all grades of society, and 
is within the resources of the ordinary family. The printed list is 
given near the end of gestation to the patient, who provides the 
whole or such parts as she can afford. 

"Labor. — Towels; one-half pound of ether; two ounces of 
brandy ; four ounces of tincture of green soap ; six ounces of lysol ; 
skein of bobbin or coarse silk ; bed-pan, preferably of tin (price 
seventy-five cents); one pound of absorbent cotton; one ounce of 
eucalyptol in vaseline (thirty minims to the ounce) ; two yards of 
unbleached muslin for binder ; five-yard package of gauze ; eight 
yards of cheesecloth (roll up in a newspaper, bake in the kitchen 
oven until the paper is scorched, and leave rolled up until called 
for) ; two yards of rubber cloth or table-cover. 

"Baby Clothes. — Four to six dozen diapers; two or three pairs 
of knit woollen socks ; three or four woollen shirts ; four flannel 
night-skirts, for pinning-blankets ; six to ten slips; one yard of 
fifty- or sixty-cent flannel for bands ; knit woollen wrapping blanket. 

" Baby s Basket. — Large and small safety pins; plain talcum 
powder, box and puff; soft brush for baby's hair; castile soap; 
cold cream; alcohol; old linen for cleansing baby's mouth; soft 
towels for bath; bath blanket." 

This list does not include a fountain syringe ; it is an unneces- 
sary expense, as the ordinary nurse is not to give douches. 

The following directions are given to the patient : That she 
take a full dose of castor oil (or other cathartic) the night before 
the expected day of confinement ; that she or the nurse roll up 
one-half dozen towels and napkins into a loose bundle, wrap them 
in a newspaper, and bake in the kitchen oven until the paper 



LABOR: ITS PHYSIOLOGY AND PREPARATION. 151 

is well scorched. As soon as pains begin the bowels are to be 
moved, either by natural effort or a soap-and-water enema. 

Instructions When to Send for Physician and Nurse. — Those 
patients who have been during the last of gestation under the su- 
pervision of the physician are taught the ordinary symptoms of 
early labor, and directed to summon him and the nurse when pains 
are regular every fifteen minutes or if the membranes have broken. 
This is usually in time for correction of any malposition, and pre- 
vents needless professional waiting. 

The Obstetric Hand-bag. — The bag itself. The important ob- 
jection to the ordinary commercial obstetric satchel is that it can- 
not be kept clean. It is, of course, impossible to sterilize it by 
washing with germicides or in a regular hospital sterilizer, and is 
too expensive to be often renewed. Besides, its capacity is limited 
to its ordinary contents, allowing no additional space for emergen- 
cies. In its place is suggested the common canvas extension bag, 
ten by eighteen inches in size, and costing $i. It can be easily 
sterilized by a solution of forty-per-cent formalin, is large enough 
to carry, besides the necessary instruments and other articles, two 
agate iron basins for chemical solutions, and when required can 
be enlarged to nearly twice its ordinary size. 

The necessary armamentarium of the obstetrician should be 
a jute nail-brush, box of green soap with metal cover, bottle of bi- 
chloride and normal salt tablets, four ounces of lysol, one ounce 
of fluid extract of ergot or ergotole, four ounces of A. C. E. mix- 
ture (one part alcohol, two parts chloroform, and three parts 
ether), small package of absorbent cotton, five-yard package of 
gauze, a long obstetrical forceps and Reynolds' traction rods, two 
pairs of Kocher's haemostatic forceps, needles with large eyes 
for catgut, bottle of No. 2 or medium catgut, a transfusion needle, 
Neilson's or Bozeman's intra-uterine douche, and a two-quart 
fountain syringe. 

This list may be indefinitely enlarged, but has proved amply 
sufficient for ordinary cases. If the weight of the hand-bag is not 
important, there can be added a sling bandage for holding the legs 
during operations, short obstetric forceps, needle forceps, double 
tenaculum and long sponge forceps, Kelly rubber pan, gown, and 
rubber apron. It is supposed that the ordinary hypodermic case, 



152 THE PRINCIPLES OF OBSTETRICS. 

which every physician carries, will supply morphine, strychnine, 
and trinitrin, and his pocket case the necessary scissors, bistoury, 
etc. 

All instruments and other metallic articles should be carried 
in canvas bags, sterilized either in an Arnold's sterilizer or by boil- 
ing at the office, and are thus ready for immediate service in 
emergencies at the bedside. Liquids should be kept in glass- 
stoppered bottles with metal covers (sold by instrument dealers), 
powders sterilized by baking, and gauze wrapped in cloth, steril- 
ized in the package and unopened until actually needed. 

Antiseptic Preparations at the House. — Metallic instruments 
may be boiled upon the kitchen stove in a solution of carbonate 
of sodium (one teaspoonful to the pint) (which prevents rusting 
and is a much more active germicide than plain water) ; napkins, 
towels, etc., baked in the oven for half an hour; gauze for the 
cord and possible uterine tamponade is brought to the bedside 
direct from the office sterilizer, and a fresh laundered sheet may 
take the place of the gown. The commercial pot of vaseline 
should be banished from the lying-in room, a solution of lysol be- 
ing substituted as a lubricant. Ordinary soap is practically ster- 
ile, although green soap is preferable. The physician's hands 
should be sterilized by washing in hot water and green soap for 
five minutes, then in bichloride solution (i to 1,000), preceding 
all vaginal examinations by washing them with lysol solution (one 
per cent, or one drachm to the pint). Lysol is a lubricant as 
well as a germicide, and is composed of neutral soap, cresol, and 
water. The Maine State Board of Health, after thorough inves- 
tigation, recommends it for sterilizing because " disinfection of the 
hands is assured by using a one per cent solution without the 
previous use of soap ; a one-fourth per cent solution renders in- 
struments sterile and does not attack the instruments. It is eight 
times less poisonous than carbolic acid and much less so than 
sublimate." 

If a trained nurse is present, she will make all preparations for 
delivery, attend to the sterilizing of the water, towels, napkins, 
etc., and her hands before touching the genitals of the patient. 



CHAPTER II. 
CONDUCT OF NORMAL LABOR. 

FIRST STAGE. 

Abdominal Examination. — The patient is asked to go to her 
bedroom, remove all clothing except the undervest, put on a clean 
night-dress, and get into bed. The abdomen is then carefully 
examined, according to the method described in the preceding 
chapter, for the presentation, position, and the size of the child, 
together with the amount of liquor amnii estimated. During the 
physical examination she is asked about the condition of the intes- 
tines and bladder, the history of previous labors (if any, or if she 
is a stranger), and such other questions as would be natural under 
the circumstances. These inquiries are not only useful to the 
physician, but also serve to introduce him to his patient. 

Preparation of Lying-in Room and Bed. — If the confinement 
is to be in a dwelling, a sunny, well-ventilated room should be 
selected, when possible, situated as far as practicable from the 
kitchen and living-room, and without a set wash bowl. It is not 
necessary to carry away ordinary furniture, but the carpet should 
be well swept and the woodwork thoroughly washed before occu- 
pancy. In most cases the family bedstead must be used for de- 
livery, its main objections being that it is too low down for opera- 
tive work and the springs sag too much in the centre. When 
artificial delivery is required, a kitchen table, covered with a folded 
quilt, can be substituted for the bed, its increased height being a 
decided advantage. The mattress should be firm and hard ; a 
feather bed, being manifestly unsuitable for the occasion, should 
be discarded. Upon its centre should be placed a quilt folded 
square, over which should be spread in the usual manner a 
fresh laundered sheet. These should be protected by a rubber 
sheet, table-cover, several thicknesses of newspapers, or a special 

153 



154 



THE PRINCIPLES OF OBSTETRICS. 



pad, one yard wide, made of layers of cotton batting, cotton waste, 
or piece of old quilt, and covered with cheesecloth. Upon the 
protective a sheet, folded lengthwise, should be laid across the 
bed for a draw sheet, the corners being pinned down with safety 
pins. 

Toilet of the Birth Canal. — The woman is now requested to 
lie down upon the right side of the bed, remaining upon her left 
side. Her clothing is then rolled up to the breasts, fastened with 
safety pins, and she is covered with the usual upper sheet. If 




Fig. 48. —Protective Arranged to Conduct Away Fluids. 



she is lying upon a protective, its free edges are pinned together 
so that fluids will be conducted into a receiver under the bed, or 
a common quilt can be arranged in the same manner. The Kelly 
rubber pad is invaluable for this and other operative work. 

As soon as the bed is ready, the physician sterilizes his hands, 
puts on a gown or has a sheet pinned about him, and makes the 
toilet of the birth canal. After clipping the long vulvar hair, 
the external genitals, anal cleft, inside of the thighs, and pubic 
region are thoroughly washed with hot water and green soap, and 



CONDUCT OF NORMAL LABOR. 



155 



rinsed with bichloride solution (i to 2,000) or lysol one per cent. 
If gonorrhceal or other specific infection of the passage is sus- 
pected, the vagina must be included in the disinfection ; washed 
first with soap and water, well rubbed into the vaginal surface 
with pledgets of absorbent cotton held in a sponge forceps, then 
with bichloride solution (1 to 2,000), and finally douched with nor- 
mal salt solution. While absolute sterilization of the birth canal 
is clinically impracticable, the method de- 
scribed will reduce the danger of infec- 



tion to a minimum. Personal infection 
is prevented by the use of rubber gloves, 
which are almost indispensable under 
these special conditions. 

It is a fair question whether in some 
cases it might not be advisable to shave 
the pudendum, the only valid personal ob- 
jection being the discomfort that follows 
when the hair begins to be renewed. Or- 
dinarily it is sufficient to cut the long 
hair, thus removing an evident source of 
infection from retention upon it of co- 
agula and other discharges. After the 
toilet, the parts are to be protected by a 
sterilized napkin, which is to be renewed 
after each urination or defecation. 

In default of a trained nurse, all these 
details of preparation should be attended to by the physician him- 
self, as the common monthly nurse cannot be trusted with them. 
Such duties are in no wise derogatory to his professional dignity, 
and are important links in the chain of aseptic midwifery. 

Vaginal Examination. — After resterilizing his hand, the physi- 
cian makes his first vaginal examination, beginning just before a 
pain and continuing through the next succeeding one, noting the 
condition of the vagina and rectum, the shape and amount of dila- 
tation of the os, the degree of protrusion of the membranes, and 
the variety of presentation (cephalic, breech, or shoulder). The 
diagnosis of position by digital examination is never so trustworthy 
as by abdominal palpation and auscultation, and is liable to infect 




FIG. 49.— Kelly Rubber Pad. 



15(5 THE PRINCIPLED OF OBSTETRICS. 

the canal. As lysol is both a germicide and a lubricant, the hand 
may preferably be bathed in a solution of it rather than bichloride, 
before every vaginal examination, thus doing away with any spe- 
cial unctuous material. Frequent vaginal examinations are un- 
necessary, but may ordinarily be repeated about once every hour 
during a prolonged first stage to ascertain the progress of dilata- 
tion, to detect a possible prolapse of the cord, or the pinching of 
the anterior uterine lip between the head and symphysis. 

If the combined examinations indicate a natural delivery, it 
is advisable to let the patient alone as much as possible, many 
women doing better if the physician leaves the house for a time. 
Changes of position, like withdrawing from the bed, walking about 
the room, or sitting in an easy chair, rest her as well as divert 
her attention from the suffering. 

Minor Details of Arrangement. — Order and method are no- 
where more desirable than in the lying-in chamber. It is impos- 
sible to use ordinary bedroom furniture, like a bureau, dressing- 
tables, chairs, etc., for holding instruments and surgical materials, 
and yet preserve the desired asepsis. In almost every house a 
small table can be found which may be adapted to the convenience 
of the physician. During the last of the first stage it can be 
placed near the bed, wiped clean and covered with a sterilized 
towel, and such articles laid upon it as will be needed in delivery : 
ergot, starch for dressing the cord, haemostats and scissors, catgut, 
needles and needle-holder, packages of absorbent cotton and gauze, 
a cup of vinegar for hemorrhage, and hypodermic syringe filled 
with a solution of strychnine, one-thirtieth grain. An agate-iron 
basin or common washbowl, thoroughly washed, may also be placed 
upon the table if there is space, or if not upon a chair covered with 
a clean sheet, half full of a germicide solution (lysol or bichloride) 
of moderate strength, and a number of sterilized napkins. 

Anaesthesia during the First Stage. — Surgical anaesthesia 
should be reserved for operative deliveries, but the primary degree 
is useful at this time in dulling the acuteness of suffering and for 
dilating the cervix. Anaesthesia ought not to be a routine in any 
stage of natural labor when contractions are well borne, ether 
often inducing an hysterical condition and chloroform in excess 
paralyzing uterine action besides predisposing to post-partum 



CONDUCT OF XOEMAL LABOE. 157 

hemorrhage. The A. C. E. mixture has certain advantages for 
minor anaesthesia, being safer than pure chloroform and acting- 
more speedily than simple ether. During the last of the dilating 
period a few drops of it can be inhaled at the beginning of a pain 
from a large handkerchief held by the patient herself and removed 
when it ceases, or from an Esmarch mask or Allis inhaler. 
Chloroform or the A. C. E. mixture can be substituted for ether 
in the list of articles to be provided for labor, according to the 
wishes of the physician. 

Fomentations with very hot water over the lumbar region will 
relieve the backache characteristic of this stage much better than 
the usual pressure made by too energetic sympathizers. If dila- 
tation is slow and very painful, chloral, fifteen grains per orem 
every half-hour for four doses, or an enema of bromide of potas- 
sium and chloral, of each one drachm, may be prescribed. Many 
obstetricians prefer a hypodermic of morphine and atropine for 
the same indications, but caution should be taken not to leave the 
patient long afterward, since birth will sometimes follow unex- 
pectedly. Strychnine may be given for maintaining strength and 
promoting good contractions after delivery. Light food should 
be taken at regular intervals, hot tea, bouillon, milk, egg-nog, etc., 
and attention paid to urination and defecation. 

During the first stage of labor the duties of the obstetrician 
are chiefly recognition of the presentation and position ; beyond 
these, his relations to the patient are advisory rather than active. 

SECOND STAGE. 

Position of the Patient. — The bed shovM be taken at the be- 
ginning of this stage, because pains are more severe while she is 
upright, and one of the child's extremities or a loop of the cord might 
be washed out of the uterus in a sudden evacuation of liquor amnii. 
Precipitate delivery has often occurred when a woman in child- 
birth was standing or using a commode, the cord breaking and the 
child being injured or even killed by the accident. Passive suffer- 
ing of the former stage is now changed for strong active labor, the 
woman holding her breath during each contraction and bearing 
down with all her power, many insisting also upon pulling upon a 



158 THE PRINCIPLES OF OBSTETRICS. 

sheet or towel tied to the foot of the bed. If descent is slow with 
infrequent pains, these voluntary efforts are needlessly tiresome 
and should be discouraged. 

It is usual for women in this country to be confined in the 
English position, lying upon the left side near the right edge of 
the bed, or across it. The Continental dorsal position exposes the 
person more than the other, is less convenient for professional 
manipulations, and increases the risk of laceration of the outlet. 
Many women of the lower class, either instinctively or from the 
force of example, insist on kneeling upon the floor during the sec- 
ond stage, resting their head and arms upon a chair or bed, and 
certainly greater expulsive power can be applied in this posture 
than when reclining. Theoretically the attitude in delivery should 
be upon that side toward which the back of the child gravitates 
(L. O. A., mother on the left side; O. D. P., mother on the right 
side), but clinically she will often turn squarely upon the back 
when the head is on the perineum, in order that every atom of 
strength may be used to hasten the termination of suffering. 

Rupture of Membranes. — Great care should be taken in exam- 
ining by the vagina not to break the membranes until their dilat- 
ing work is entirely ended ; but when the cervix is fully opened 
they may be punctured, unless spontaneously ruptured, during a 
pain with the finger nail or some instrument like a probe or one 
blade of the scissors, previously sterilized. 

Anaesthesia during the Second Stage. — If suffering can be 
lessened without detriment to the progress of delivery, humanity 
as well as the principles of obstetric art require it. At the be- 
ginning of a contraction a few drops of the A. C. E. mixture or 
chloroform may be inhaled from a handkerchief or towel, lifted at 
its middle so that it will not touch the skin. If ether is selected, 
several drops will be required at each respiration, and generally 
it should be reserved for operative work, though many obstetri- 
cians use it to the exclusion of any other variety of anaesthetic. 
During the last few pains preceding birth either of the three 
mentioned may be pushed to full unconsciousness, not only for 
relief of pain, but also for moderating too hasty expulsion and re- 
laxing the perineum. Before administration examine the heart 
(and if found diseased substitute ether for chloroform), remove 



COXDVCT OF JSORMAL LABOR. 



159 



any artificial teeth, have the head low, and protect the lips and 
nose with vaseline or cold cream. 

Management of the Perineum. — The aim of all management 
of the perineum during birth is to compel the greatest amount of 
relaxation with the least degree of force. The head, being less 
compressible than the breech, claims most attention and ought to 
move with its shortest diameter in the axis of the canal, the occi- 
put rotating under the pubic arch while the face is being driven 




FIG. 50.— Playfair Method of Protecting the Perineum. (See page 160.) 



along the floor of the perineal channel, according to the mechan- 
ism described in the previous chapter. When the outlet is 
stretched to its utmost and the widest diameter of the head (bi- 
parietal) is just about to emerge, all bearing down should be for- 
bidden, and if necessary checked by full anaesthesia. Any fecal 
discharges squeezed out of the rectum by passage of the head 
should be wiped away upon pledgets of absorbent cotton or a nap- 
kin wet in lysol or bichloride solution. 



160 



THE PRINCIPLES OF OBSTETRICS. 



The simplest method of preventing laceration of the outlet is 
that recommended by Playfair: "The thumb and forefinger of the 
right hand are placed along the sides of the perineum, when it 
can be gently pushed forward over the head at the height of the 




FlG. 51.— Episiotomy, Showing Position and Direction of the Incision. 

pain, while the tips of the fingers may at the same time press upon 
the advancing vertex so as to retard its progress, if advisable." 
(Fig. 50.) Most of the pressure should be with the thumb and 
fingers, not the palm. Of other methods suggested, the following 
is serviceable : Rest the left arm upon the woman's upper buttock, 
grasping the child's head with the corresponding hand to control 
its movements, while the other pushes upward as just described. 
Birth should take place between, not during, pains. 

By either of these plans the head or other presenting part is 
under perfect control of the physician, until sufficient relaxation of 
the soft parts and necessary extension are obtained. Mere push- 
ing upon the perineum does not cause extension and invites rup- 



COXDUCT OF X0B2IAL LABOR. 161 

ture. Delivery of the face by rectal expression ("shelling out") 
is objectionable, because uncleanly and liable to injure the rectal 
mucous tissue; for these reasons the Playfair method is preferable. 
During perineal pressure a napkin wrung out in hot lysol solution 
should be placed between the hand and opposing surface. Fo- 
mentations with very hot water applied continuously to the peri- 
neum while dilating assist in its relaxation and secondarily relieve 
the pain of distention. 

Episiotomy. — If rupture of the perineum appears inevitable, 
episiotomy can be made when the vulvar ring is at its greatest 
strain under pressure of the parietal eminences. The cord-like 
ring, felt just within the tense border of the vulva during a pain, 
is divided bilaterally by a blunt-pointed bistoury or scissors, the cut 
being about one inch long and one-quarter of an inch deep, at a 
point about one-third way from the posterior to the anterior com- 
missure when the parts are upon the stretch (Fig. 51), and after 
delivery is stitched with fine catgut (Fig. 52). It requires ex- 
perience to recognize when the opera- 
tion is advisable, but occasionally it is 
very useful. j^ 

It is a serviceable expedient to turn 
the head to one side when it is escaping, ■ >\ 

so that the projecting nose and chin, 
the edges of sutures, and later the acro- 
mion and olecranon may not tear the 
perineal raphe. After the head is born 
the finger should be passed under the 
symphysis to detect any coils of the cord 
around the neck, an accident that occurs 
about once in every four births. If pres- 
ent, draw upon that loop which gives 
most readily, and slip each coil over the 
head or shoulders; if this is impossible, fig. 5 2.-E P isiotomy, and 

. .. Method of Suturing Wound. 

apply two haemostats or ligatures to any ( Se e page 160.) 

part of the cord which can be reached 

most easily, and cut between them, afterward extracting the 

child as quickly as possible to prevent asphyxiation. 

The face, soon after birth, begins to swell and turn purple 
11 




162 THE PRINCIPLES OF OBSTETRICS. 

from pressure of blood into it from the body and interference 
with return circulation by closure of vessels in the neck. This is 
ordinarily not an indication for hasty delivery, which would be 
likely to injure the child or perineum, but after holding the head 
in the hand for a few moments it should be lifted up toward the 
mother's abdomen, in a direction continuous with the pelvic axis. 
The upper shoulder will then pass under the symphysis, and the 
lower escape from the outlet ; if the latter delays, a finger should 
be passed into the vagina, and traction made upon the axilla rather 
than externally by the hands upon the head, because forcible 
stretching of the neck might injure the brachial nerve trunks or 
even kill the child. 

Treatment of the New-born Child. — In natural delivery, as soon 
as the head even is born attempts at respiration are often made, 
and after complete birth breathing and crying usually follow im- 
mediately. The child should be wrapped in a warm blanket, laid 
upon its right side to promote closure of the foramen ovale, and 
put in a dry place as far from the mother as possible without 
overstretching the cord. If the child is partially asphyxiated, as 
shown by cyanosis of the face and body with full pulsations of the 
cord (apncea livida), the latter should be cut and allowed to bleed 
untila better color appears. A finger wrapped in gauze or linen 
should be passed into the fauces to clear away mucus, breathing 
encouraged by rolling the child from side to side, gently slapping 
its back or sprinkling it with cold water. If when born it is life- 
less, with slow heart beat and cord pulseless (apncea pallida), re- 
suscitation should be attempted by methods described later. 

Ligation of the Cord. — Experiments demonstrate that the child 
receives two or three ounces of blood after birth, partly from di- 
rect uterine compression of the placenta, partly from aspiration of 
the vessels of the cord due to the action of its respiratory mus- 
cles. When, therefore, there is vigorous crying or the cord stops 
pulsating, a haemostat may be fastened upon it, permanent liga- 
tion being deferred until after the child is washed or performed 
immediately. A piece of bobbin, coarse silk, or strong cotton 
twine a foot long, previously boiled or soaked in bichloride or lysol 
solution, is passed twice around the cord, from which the Wharton's 
jelly has been squeezed, about an inch and one-half from the body, 



CONDUCT OF NORMAL LABOR. 163 

drawn tightly, and tied in a double surgical knot. If the cord is 
unusually thick, a second wrap will secure its vessels more safely, 
and in case of twins a double ligature or two haemostats must be 
used, in order that the second child may not bleed to death from 
anastomosis of placental vessels. The cord is now held between 
the fingers, as illustrated in Fig. 53, so that none of the child's 
fingers or toes, or possibly the penis, may be included with it, and 




FIG. 53.— Method of Holding the Funis When Cutting it. 

severed with sterile scissors about half an inch from the ligature 
or haemostat. The child, well wrapped up, is then given to the 
nurse or laid in its crib, while attention is given to delivery of the 
placenta. 

THIRD STAGE. 

In the third stage of almost every labor two duties engage the 
attention of the obstetrician : delivery of the placenta and preven- 
tion of hemorrhage. As obviously the latter is most important, 
it should receive attention first, and its success depends upon secur- 
ing and maintaining firm uterine contraction . Natural haemostasis 
is intensified by internal and external stimulants, ergot, uterine 
massage, and the abdominal binder. 



164 THE PRINCIPLES OF OBSTETRICS. 

Ergot. — Ergot is a good servant but a bad master. Great dif- 
ferences of opinion regarding its usefulness in labor prevail among 
obstetricians, some giving it in all cases, others never doing so. 
The middle course between these extremes is probably the wiser, 
remembering always that it produces, not natural intermittent 
contractions, but rather a continuous tonic spasm of the uterus. 
It is therefore contraindicated as an expulsive during the first and 
second stages when any obstruction, mechanical or organic, exists 
to delivery, and should ordinarily be reserved for its haemostatic 
action in the third stage. During that period it is conceded to be 
a prophylactic against hemorrhage and sepsis, lessens after-pains, 
prevents retention of coagula, and promotes involution. If given 
before expulsion of the placenta, it may cause so firm a closure of 
the uterus that the former may require manual extraction. On 
this account it is safer to withhold ergot in natural labor until the 
uterus is empty, when a full dose, one drachm of the fluid extract, 
may be given in water per orem, or fifteen minims of ergotole in- 
jected deep into the gluteal muscles, instead of into the cellular 
tissue where it may cause abscess, its action being expected in 
about twenty minutes. 

Manual Uterine Compression. — As soon as the child's head 
passes out of the mother, the physician should grasp the uterus 
through the abdominal walls, making firm pressure upon it with 
the whole hand and compelling it to clasp the child's body closely 
during its expulsion. Massage by rubbing or kneading motions 
is usually unnecessary, and may cause premature detachment of 
the placenta. This manipulation should be a routine in all cases, 
and can be judiciously taught to the nurse, even if very ignorant. 
Finally, after the placenta is expelled, the binder should be ap- 
plied, which continues the former pressure of the hand, adding 
greatly to the woman's comfort by maintaining intraabdominal 
pressure and preventing cerebral anaemia. It can be extempo- 
rized from any strong cloth, or may previously be made from un- 
bleached cloth, one and one-half yards long, wide enough to reach 
from just below the trochanters up to the false ribs, and pinned 
from above downward. An abdominal pad of a folded napkin, laid 
above the umbilicus under the binder, may or may not be used, 
according to the custom of the practitioner. 



CONDUCT OF NORMAL LABOR. 



165 



Delivery of Placenta. — Generally speaking, the placenta should 
be driven rather than dragged out, and it is good routine practice 
to wait for three firm contractions before attempting its removal. 
If twenty or thirty minutes after delivery (during which time 
manual uterine pressure has been continuous) the placenta is still 




Fig. 54.— Abdominal Binder Applied. 

not expelled, the method first systematically proposed by Crede 
in 1 861 should be tried. Place the patient squarely upon the back, 
grasp the uterus in the hand, the fingers upon the back of the 
fundus and the thumb upon the front, and squeeze during a pain 
downward into the axis of the pelvis. As the Crede method is 
used, the cord will be noticed to slip little by little out of the 
vagina, the uterus rises in the abdomen, and its lower segment, 
grows larger, implying that the placenta has passed out of the 
contractile portion into the cervix and upper part of the vagina. 
It then appears at the outlet or a finger will recognize it just in- 



166 



THE PRINCIPLES OF OBSTETRICS. 



side the canal, from which it can be readily extracted. When ex- 
pelled by the Crede method the uterine placental surface usually 
presents first with the cord inside the membranes; but if de- 
livered by traction, the fetal surface and root of the cord come 
first. The membranes trail after the placenta, but if they are still 
adherent draw them first toward the symphysis, then backward 
toward the sacrum, manual compression being relaxed for the 
moment to allow the uterus to dilate and permit their escape. It 
is unnecessary to twist the placenta and membranes into a cord 




Fig. 



-Crede Method of Expelling the Placenta. 



while extracting them, and they should be received into a basin 
held by the nurse between the mother's thighs. If the Crede 
method fails to deliver the placenta after an hour, and the cord can 
be traced into the uterus, indicating that the placenta is still within, 
its lower edge should be caught by two fingers inserted into the 
cervix and delivered by traction. Occasionally it may be neces- 
sary to pass the whole hand into the uterine cavity and peel off the 
placenta, after which the hand and placenta in its grasp are with- 
drawn together, an intrauterine douche of normal salt solution 
being afterward given. Postpartum flooding is largely due to too 
hasty delivery of the placenta, that is, before firm uterine con- 
tractions have been secured. 



COy DUCT OF FORMAL LABOR. 167 

The placenta and membranes should be carefully examined 
after extraction, to make sure that no portion of eitner remains 
behind. If apparently a fragment of placenta is wanting, it should 
be sought for and removed whatever its situation ; shreds of mem- 
brane remaining in the vagina should be withdrawn, but if in the 
uterus they had better be left for discharge with the lochia. 

Final Toilet After Delivery. — After natural delivery there is 
little hemorrhage and the uterus remains firmly contracted. The 
birth canal (either of the uterus, vagina, or outlet) should then 
be examined for lacerations and if found repaired according to 
the method described in the next chapter. The patient is then 
carefully washed with lysol or bichloride solution, removed to the 
fresh side of the bed, all soiled clothing replaced with clean under- 
vest a} id night-dress, a sterile napkin is applied to the vulva and 
fastened to the binder with safety pins. The protective and dirty 
bedding are carried away, a fresh draw sheet is put on the bed, 
and the room is tidied as quickly and quietly as possible. 

Care After Delivery. — The physician ordinarily should not 
leave the patient after delivery for a full hour, until the condition 
of the pulse, the temperature, the uterus, and the amount of hemor- 
rhage are satisfactory. The nurse should be directed to examine 
the uterus through the binder every half -hour to see that it is well 
contracted, the napkin for the amount of flowing, and within an 
hour the cord for possible bleeding. Full instructions are also 
given regarding the patient's diet, sleep, urination, after-pains, and 
treatment of excessive hemorrhage while the physician is absent. 
It is expected that the room will be kept quiet, and all visitors ex- 
cept immediate relatives excluded. 



CHAPTER III. 
THE PUERPERIUM. 

PHYSIOLOGY. 

The puerperium (puer, a boy, and parere i to bring forth), the 
puerperal state or lying-in, includes the time from the end of labor 
until return of the uterus to its natural size, a period of about six 
weeks. 

Post-Partum Chill. — Owing to exposure of the body during 
delivery, evaporation of sweat, abrupt cessation of muscular effort, 
and loss of heat to the mother from removal of the child, many 
women have after-labor rigors, shivering, or a distinct chill, which 
have no pathological importance, soon passing away with extra 
bed-clothing and a cup of some hot drink. 

Pulse and Temperature — Immediately after childbirth the full, 
rapid pulse of muscular exertion decreases from the normal rate 
to 60 or even 40, and this is a favorable indication ; when, on the 
contrary, it continues fast, above 100, it should warn the physician 
that flooding is likely, and he ought not to leave the patient until 
firm uterine contraction is secured. 

Many women preserve a normal temperature of 98. 5 ° F. 
.throughout the lying-in, though it is generally elevated a few tenths 
of a degree at the close of labor. Obstetricians are agreed that 
a temporary rise up to ioo° F. within the first few days is physio- 
logical, but beyond that point symptomatic of infection. 

Secretions and Excretions. — As a part of the process of restor- 
ation of the reproductive system to the natural unimpregnated 
condition, all emunctories are active. The breathing is slower, 
the urine collects in the bladder rapidly, sweating is profuse, and 
as a result thirst is prominent. The bowels are sluggish, appe- 
tite is poor, glycosuria is common, and peptonuria natural to the 
puerperium. 

168 



THE PTJERPERIUM. 169 



CHANGES IN THE REPRODUCTIVE SYSTEM. 

Uterus. — After natural labor the upper segment is firm and 
condensed, the lower remaining flabby and patulous for several 
days, but gradually regaining its normal tone. The greater part 
of the mucous lining becomes loosened and is discharged with the 
lochia, the remainder forming a new endometrium within six 
weeks or two months. The placental site is a slightly raised patch 
with small coagula projecting from the mouths of the vessels. At 
first the cavity fills with blood and clots, later it is covered with a 
reddish-gray film of blood and fibrin. The cervix is flaccid and 
shapeless at the close of labor and its mouth is more or less lacer- 
ated, but reconstruction begins after twelve hours, the os inter- 
num admitting two fingers at the end of twenty-four hours and the 
os externum one finger up to ten or fifteen days. 

Involution. — After childbirth retrograde changes, largely fatty 
degeneration from lessening of blood supply, occur in all the 
structures of the genital tract, the process being called involu- 
tion. Immediately after delivery the fundus, when well contracted, 
is midway between the pubes and the umbilicus, in a few hours at 
the umbilicus, and under normal conditions has descended on the 
tenth day to the level of the brim. Ordinarily involution is com- 
plete after about six weeks, but is retarded by causes such as twin 
gestation, failure to nurse, severe hemorrhage, infection, and too 
early getting-up, though the parous uterus and the remainder of 
the birth canal are never again quite as small as before the first 
pregnancy. 

After-pains. — Painful cramp-like contractions after delivery are 
due to successive attempts to expel blood and coagula which result 
from relaxation of the uterus, and are intensified reflexly by nurs- 
ing. After-pains are uncommon in primiparse, in whom haemo- 
stasis is more perfect than in subsequent gestations, unless labor 
has been operative, precipitate, or tedious ; but they are universal 
in multiparae, owing to less efficient and infrequent contractions 
from weakness of the uterine muscles, They are distinguished 
from the pain of inflammation by normal pulse and temperature, 
and generally disappear after the third or fourth day. 



170 



THE PRINCIPLES OF OBSTETRICS. 




Fig. 5 6. 



-Colostrum Corpuscles. 
(See page 171.) 



(Chapin ) 



Lochia. — The vaginal discharges that follow delivery are called 
the lochia (/"/"?, pertaining to a woman in childbed), and were 
formerly distinguished by special names, according to their ap- 
pearance: for the first five 
days, when almost wholly 
blood with decidual and pla- 
cental fragments, they were 
called lochia rubra; for two 
or three days later, when 
serum and blood, lochia om- 
enta; and, finally, for about 
two weeks, when composed of 
degenerated epithelial cells, 
micro-organisms, cholesterin, 
and pus from granulating 
wounds of the canal, lochia 
alba. The total quantity, 
three-quarters of which is dis- 
charged during the first three or four days, is about three and one- 
quarter pounds ; this is clinically measured by the number of nap- 
kins required in twenty-four hours, generally one every four hours 

during the first four days, 
more than this being consid- 
ered pathological. 

Persistent bloody flow dur- 
ing the third week is sugges- 
tive of retrodisplacement, par- 
ticularly if accompanied w r ith 
sacralgia. The odor of the 
lochia at first resembles that 
of raw meat, later is that pe- 
culiar to the genitals, but when 
offensive it indicates septic in- 
fection and requires appropri- 
ate treatment (see chapter on 
Puerperal Septicaemia). 
Vagina and Outlet. — The canal below the uterus is always 
more capacious after than before childbirth, rugae largely disap- 




FlG. 



-Normal Human Milk. 
(See page 171.) 



(Chapin.) 



THE FUEKPERITJM. 171 

pear, and the perineum is lacerated in from fifteen to thirty five 
per cent of primiparae and in about ten per cent of multiparas. 

Abdomen. — The abdominal walls are relaxed for several weeks, 
usually permanently so after repeated gestations, and striae form 
upon its surface and the outer portion of the thighs. 

Other Associated Structures. — All organs and structures of the 
body participating in the hypertrophy of pregnancy unite with the 
uterus in the process of involution. 

Breasts. — The breasts remain passive for three or four days 
after labor in primiparae, generally a day less in multiparae, the se- 
cretion during this time being colostrum — a thin yellowish fluid 
composed of epithelial cells, fat globules, colostrum corpuscles, 
proteids, and saline matters — which is moderately laxative. The 
glands then become functionally active, are swollen, tense, and 
painful, causing decided constitutional excitement, with slight rise 
in bodily temperature, headache, and restlessness. True milk is 
now secreted, alkaline in reaction, sweet, and bluish-white in color, 
colostrum disappearing entirely by the tenth day. 

Signs of Recent Childbirth. — Most of the changes detailed 
above are present in a woman who has been recently delivered : 
enlargement of the uterus and possibly contractions, softness and 
lacerations of the cervix, relaxed vagina with gaping and unhealed 
outlet, lochia, and secretion of milk. The abdominal parietes are 
flaccid, and striae are present upon them and the hips. 

MANAGEMENT OF THE PUERPERIUM— THE MOTHER. 

Visits. — It is impossible to prescribe definite rules for the fre- 
quency of professional visits after labor, much depending upon its 
character, the station in life of the family, and local customs. For 
the strong, healthy laborer's wife, a daily visit is ordinarily suffi- 
cient until lactation is established ; for the higher classes, once or 
twice daily for the first week, a daily visit for the second week, 
and occasionally afterward until ordinary occupations are re- 
sumed. 

First Visit. — The first visit after birth should be made within 
twelve hours, when the condition of both mother and child should 
be carefully investigated. Take the pulse and temperature of the 



172 THE PRINCIPLES OF OBSTETRICS. 

mother, loosen the binder, and palpate the uterus to find if it is 
well contracted or the bladder distended, inquire for the amount 
of urine passed, the quantity and quality of the lochia, and whether 
she has slept and what has been her diet. Ask if the baby has 
urinated and passed meconium, whether there is any discharge 
from its eyes or hemorrhage from the cord, and take its rectal 
temperature. 

Daily Visits. — The daily visit should develop a full clinical his- 
tory of both patients from examination of the pulse and tempera- 
ture, the lochia and after-pains, urination, defecation, the condition 
of the mother's breasts and nipples, and the degree of involution. 
Find out if your directions regarding sleep, diet, and number of 
visitors have been observed, whether the child has been comfort- 
able through the night, and is bundled up too much. Only by 
methodical questioning and examination can those slight variations 
from health be detected, which, apparently trivial to-day, may de- 
velop into serious complications to-morrow. 

After-pains — If these are severe the indication is to secure 
contractions and relieve distress. Ergot may be given in half- 
drachm doses every three hours ; chloral, paregoric, suppositories 
of opium or preferably morphine hypodermically. A useful com- 
bination is phenacetin five grains, codeine one-half grain, and caf- 
feine one grain ; repeat every hour for three doses. Sometimes a 
good cathartic will expel the coagula, particularly if the patient is 
permitted to sit upon the commode while defecating. Manual 
emptying of the uterus, when exceptionally necessary, should be 
performed under the strictest antiseptic technique, and be fol- 
lowed by an intra-uterine douche of normal salt solution. 

Lochia. — The golden rule in modern obstetrics is " Preserve 
the asepsis." In private practice vaginal douches are not to be 
given by the ordinary nurse, but when necessary, for infection or 
offensive lochia, by the physician or graduate nurse. Vulvar nap- 
kins, previously sterilized and kept so until in contact with the 
pudendum, should be changed every four hours during the first 
three days, and before touching them the nurse must thoroughly 
wash her hands in hot water and soap. When the napkin is to be 
renewed, the patient should be placed upon a bedpan, and the 
lochia upon the labia and neighboring region washed off" by affu- 



THE PTJERPERIUM. 173 

sion with a pitcher of lysol (one-half of one per cent) or bichloride 
solution (i to 2,000). 

Urination. — Excretion of urine is increased after delivery, but 
owing to paralysis of the bladder from former uterine pressure, 
wounding of peri-urethral tissues, and urethral spasm, retention, 
especially in primiparae, is frequent. Relief should be attempted 
first by posture, either upon the hands and knees, or, if there is 
no contraindication, sitting upon the commode in bed, supported 
meanwhile by the nurse. Various expedients to induce urination 
can be tried, like allowing the patient to hear water trickle into 
a basin, applying hot sterilized napkins over the bladder and 
meatus, etc. 

Catheterization. — The catheter should be used if natural efforts 
fail after twenty-four hours, and invariably after perineorrhaphy, 
according to the following method : Have the woman lie upon her 
back, wash the external genitals with pledgets of cotton or linen 
saturated with lysol or bichloride solution, separate the labia with 
sterile fingers, and cleanse the outlet in order that none of the 
lochia may be carried into and infect the bladder. Expose the 
meatus to sight, and pass a soft-rubber catheter, sterilized and 
lubricated with lysol solution, or, if bichloride is used, after rins- 
ing with plain boiled water and anointing with sterile vaseline, or 
with the same and eucalyptus (30 gr. to § L). The old unclean 
method, passing the catheter upon the finger in the vagina with- 
out seeing the meatus, is almost sure to infect the bladder and 
should be condemned. Urine ought not to be permitted to flow 
over the vulva, but should be collected in a basin, and after each 
natural urination the patient should be placed upon a bedpan and a 
pitcher of lysol or normal salt solution poured over the pudendum. 

Defecation. — The intestines being usually sluggish after labor 
and requiring some form of stimulant, it is a serviceable routine to 
give a Seidlitz powder or two drachms of Epsom salts in an ounce 
of hot water the third morning. If no results follow through the 
day, prescribe a heaping teaspoonful of compound liquorice pow- 
der, one-half ounce of castor oil, or two or three compound cathar- 
tic pills the same night. On the fourth morning, if there is tym- 
panites, direct an enema of soap suds with one drachm of turpen- 
tine. Care should be taken in cleansing the anus after defecation 



174 THE PRINCIPLES OF OBSTETRICS. 

not to carry any fecal material into the vagina, and an affusion of 
lysol solution while upon the bedpan is preferable to any deter- 
gent. 

Nursing. — All lying-in women are expected to nurse their 
children, unless prevented by deformities of the breasts or nip- 
ples, pregnancy, tuberculosis, anaemia, or recent syphilis. During 
the colostrum period the child should be put to the breast every 
four hours, and after establishment of the milk every hour and 
one-half to two hours during the day, but not more than twice in 
the night, to give the mother time for sleep and rest. Nursing 
should be from alternate breasts, and continue about fifteen min- 
utes. 

Variations in Secretion of Milk. — Secretion is scanty and of 
poor quality in from ten to twenty per cent of mothers, and is in- 
dicated by flabby breasts, frequent and unsatisfactory suckling, 
and the baby being puny and fretful. 

Treatment. — When the milk secretion is scanty, advise large 
quantities of nutritious food, particularly milk, and, though there 
are no specific medicinal galactagogues, tonics, especially strych- 
nine, are indirectly useful in stimulating general nutrition. Three 
or four drachms of somatose daily, thyroid extract one grain three 
times a day, and application to the breasts of electricity are recom- 
mended. In over-secretion, restrict food and liquids, give saline 
cathartics, and support the breasts by firm bandaging. Gentle 
massage relieves simple congestion of the glands, but if inflamma- 
tion is present it is contraindicated. 

Diet. — Until lactation is established, the diet of the puerpera 
should be restricted, because nutriment is absorbed to the amount 
of some two pounds from the involuting uterus and from the gen- 
eral increase of fat during pregnancy. Milk, eggs, and gruels are 
ordinarily sufficient until the bowels are thoroughly emptied and 
the child is nursing, when a more generous diet is necessary. 

THE CHILD. 

Toilet of the New-born Child. — As soon after birth as conve- 
nient its eyes should be bathed with two-per-cent (ten grains to 
the ounce) solution of boric acid, and if there is any suspicion of 



THE PUERPERIUM. 



175 



specific vaginitis one or two minims of Crede's solution (two per 
cent of nitrate of silver) dropped into each eye and neutralized 
with salt water. The toilet of the child should be made near a 
fire or in a warm room, commencing by thorough inunction with 
vaseline or clean lard to dissolve the vernix caseosa, and followed 
by washing with a mild alkaline soap, castile preferred. When it 
is feeble or premature, inunction alone is sufficient, washing being 
postponed for a day or two until it is more vigorous. Since the 
new-born child easily becomes chilled when bathed in the ordinary 
manner upon the nurse's knees, it is more rational to immerse it 




Fig. 58.— Method of Tying Funis. (See page 176.) 

in a small bathtub or common wooden pail, first cleansed with 
boiling water, then half -filled with blood-warm water (ioo° F.), in 
which it can be bathed and kept warm at the same time. After 
being gently dried, the flexures (neck, axillae, and groins) can be 
protected, if desired, with plain laundry starch, boric acid and 
starch ( i to 8), or unperf umed talc powder. 

Daily Bath. — A sponge bath, or when the child is vigorous 
and lusty a full bath, blood-warm and lasting not over five min- 
utes, should be given it every morning in a warm room, followed 
by gentle friction with the hand of the body and extremities, es- 
pecial care being taken not to permit it to become chilled. 

Dressing the Cord. — If ligation of the cord has been deferred 



176 THE PRINCIPLES OF OBSTETRICS. 

until now, it is attended to as has been directed (page 162). 
When tying the knot, hold each end of the ligature in either 
hand, with thumbs placed back to back, so that if the ligature 
breaks under traction the cord may not be pulled out of the ab- 
domen (Fig. 58). Pass the stump through a six-inch square of 
sterilized gauze or piece of old linen previously scorched over a 
lamp or otherwise sterilized, bury it in plain laundry starch or 
boric-acid powder, fold the gauze together and place in the left 
groin to remove pressure from the liver. Some obstetricians use 
a dressing of sterile absorbent cotton, either plain or saturated 
with strong alcohol to hasten drying of the stump. The cord 
usually falls off on the fifth day, and the navel, until well healed, 
should be covered with starch or boric-acid powder. 

Deformities. — The child should now be examined for congeni- 
tal deformities, the most common being imperforate anus, malfor- 
mations of the genitals, toes and fingers, harelip, cleft palate, and 
clubfoot. 

Dressing the Child. — In private practice it is customary to use 
the belly band of soft flannel, and, though unessential, it may be 
permitted when not pinned too tight. Then the diaper is ad- 
justed, undervest, pinning blanket, and, finally, the cotton slip, all 
dresses being preferably fastened with tapes rather than safety 
pins. Until fully clothed the child should be covered as much as 
possible to prevent chilling, which is manifested by incessant cry- 
ing and cyanosis of the extremities. m Finally, after being wrapped 
in a light blanket, it should be put in a safe place, a crib or bas- 
sinet rather than a chair or in bed with its mother, and a hot- 
water bottle or extemporized appliance for keeping it warm laid 
under the outer blanket. 

Feeding the Child. — In deference to popular opinion a few tea- 
spoonfuls of warm water and white sugar may be given the child 
after its toilet, but it is unnecessary. Within six hours after deliv- 
ery, if the mother is in good condition, it should be put to the 
breast, the nipple being first washed with soap and water and the 
child's mouth with plain water, to induce the habit of nursing, to 
gain the laxative action of the colostrum, and to stimulate contrac- 
tions. Much ingenuity is sometimes required to induce this early 
nursing, the most effectual incentive being to moisten the nipple 



THE PUERPEBIU2I. 177 

with sterile water, milk, or to sprinkle upon it a little sugar. Be- 
fore and after each suckling the nipple should be cleansed with a 
weak solution of boric acid or bicarbonate of sodium, and during 
the intervals protected from friction against the mother's under- 
clothing by a compress of gauze or linen. The child's mouth 
ought to be cleansed frequently with a mild alkaline wash, applied 
with absorbent cotton or linen wrapped upon the handle of a 
spoon. The pathology of lactation is discussed in its appropriate 
chapter. 

Urination and Defecation. — Within the first twenty-four hours 
the child usually passes a few drachms of high-colored urine ; but 
if it does not, examine its abdomen for distention of the bladder, 
and the urethra for congenital obstructions. When these are 
found normal, it may be given a hot bath or several teaspoonfuls 
of warm water with five drops of sweet spirits of nitre every two 
hours, and very exceptionally it may be necessary to pass into the 
bladder a small catheter or probe. As it has taken very little fluid, 
cases of apparent retention are really due to lack of renal excre- 
tion, and generally require no immediate attention. 

If the usual spontaneous defecation fails and examination 
shows that the anus is pervious, several drachms of sweetened 
water, ten drops of sweet oil or castor oil, or a soap or glycerin 
suppository may be given. The first evacuations will be of 
dark green meconium, changing after a few days to yellow feces. 
Diapers should be removed when soiled, and the parts thoroughly 
but gently cleansed with absorbent cotton or old linen. 

Clothing. — The number and quality of the dresses of an infant 
depend upon local customs, necessities of the climate, and pecun- 
iary abilities of the family. New-born children are ordinarily too 
much clothed rather than too little, and if possible the under-gar- 
ments should be of merino or silk rather than pure woollen, which 
is irritating to the skin ; all bands should be made loose enough to 
admit the fingers under them, and fastened with tapes rather than 
with safety pins. The flannel belly-band is worn until the cord 
separates or until the navel heals, but it is unnecessary afterward. 
12 



CHAPTER IV. 
NURSING AND SUBSTITUTE FEEDING. 

Breast Milk. — Human milk is an emulsion of fat in a clear, 
transparent fluid, in which are dissolved sugar, caseinogen, lactal- 
bumin, extractive matters, and inorganic salts. The secretion is 
derived from an overgrowth of epithelial cells lining the mammary 
ducts, their infiltration with fat and later rupture. It is alkaline 
in reaction, is secreted practically sterile, and has a specific grav- 
ity of 1.024 to 1.035. Though subject to wide variations, the fat 
averages four per cent ; the sugar, seven per cent, is lactose and 
moderately sweet ; and the proteids, one and one-half per cent, are 
casein (curd) and lactalbumin, the latter closely resembling serum- 
albumin and present only in small proportions (one-half of one 
per cent). 

Nursing. — The human infant is nourished either naturally from 
the breast of its mother or a wet-nurse, or artificially from the milk 
of other animals or by prepared foods. Unless prevented by de- 
formities of the glands or constitutional disease, it should be put 
to the breast within six hours after birth, and once in every four 
hours thereafter until true milk is established, then every two 
hours through the day, waking it upon the hour. During the 
night the interval should be as long as possible, nursing being 
permitted ordinarily not more than twice, in order that the mother 
may have the needful rest and sleep. A healthy child will empty 
the breast in about fifteen minutes, then it should be removed to 
a crib or bassinet and laid upon its right side during active diges- 
tion. Rotch says that too frequent nursing increases the solids 
of the milk and decreases the water, and, vice versa, breast milk 
otherwise good is made too watery by prolonged intervals be- 
tween the successive acts of suckling. A sedentary life with a 
diet of rich mixed food apparently increases fats and proteids and 



NUBSING AND SUBSTITUTE FEEDING. 179 

decreases water ; excess of meat and a moderate amount of fat in- 
crease fat, and physical exercise decreases proteids. 

Technique of Nursing. — Before and after each nursing the nip- 
ple should be washed by the nurse (with sterilized hands) with a 
saturated solution of boric acid or bicarbonate of sodium, in the 
mean time protecting it by a compress of gauze or soft linen. It 
is important that mothers and nurses should understand that the 
ordinary source of nursing sore breast is residual milk, which, 
becoming contaminated with micro-organisms, infects the lacteal 
ducts through either the healthy or the eroded nipple. Erosions 
are due to maceration and denudation of epithelia from too fre- 
quent or prolonged nursing (allowing the child 
to lie at night with the nipple in its mouth), 
friction against the clothing, and general un- 
cleanliness. When these appear, the child 
should nurse through a rubber nipple attached 
to a protective glass shield for twenty-four or 
forty-eight hours, when commonly under ap- 
propriate medication the erosion will heal. 
The bell of the shield should be large enough 
to permit of free exit of milk from the mother's 
fig 59.— Nipple shield nipple during suction. Deep fissures at the 
with Nipple. "base and apex are readily cured by applications 

of nitrate of silver (two per cent), or by draw- 
ing a crystal of the same through the bottom of the fissure ; ab- 
rasions, by simple lead and opium wash, glycerole of tannin, 
castor oil and bismuth (equal parts), or compound tincture of ben- 
zoin, care being taken to cleanse the surface of any medicinal 
article before permitting the nipple to be touched by the child. 
During the day the child's mouth should be washed often with 
a mild alkaline solution, applied with absorbent cotton or linen 
wrapped upon the handle of a small spoon. 

Mammary Engorgement.— Engorgement of the nursing breast 
may be relieved by salines, locally by compresses of hot water, 
either plain or medicated, gentle massage with tips of the fingers 
from the periphery to nipple, the breast pump, and, best of all, 
by firm bandaging. The Murphy bandage is easily prepared from 
strong cloth according to the figure (page 1 80), and when applied 




180 



THE PRINCIPLES OF OBSTEWMK 



early wonderfully relieves pain and distention, and promotes the 
flow of milk. 

Directions for Making and Applying the Murphy Bandage.— 
Take a piece of strong new cloth; while doubled at the line indi- 
cated in the figure, cut the neck back opening three inches wide 
and three deep, leave space of three inches ; then cut arm size six 
inches wide and nine deep, leave space of three inches, and cut 
neck front opening as indicated. When applied, open the bandage 
to its full length, place it smoothly under the patient while lying 
down, adjust the neck back opening, and fasten the shoulder pieces 
loosely together with safety pins. Draw the cloth across the 




Fig. 60. — Diagram of Murphy Breast Bandage. 



breasts, the right being lifted upward and inward by the palm of 
the patient's right hand placed outside the bandage, and the left 
breast by her left hand in similar manner. If there is much en- 
gorgement, place a roll of absorbent cotton between the breasts 
for lateral pressure. Pin with safety pins from below upward 
every two inches to just above the swell of the breasts ; while they 
are being supported as directed, draw up the shoulder pieces firmly 
and fasten with safety pins, completing adjustment by cutting an 
opening for the nipples (page 181, Fig. 61) 

Estimation of the Food Value of Breast Milk. — Of all methods 
for estimating the food value of mother's milk, the most practical 
is that of systematic weighing of the child. Six or eight ounces 
of weight arc normally lost during the first four days and regained 



NURSING AND SUBSTITUTE FEEDING. 



LSI 



before the tenth day. With a good supply of breast milk the 
child should gain from six to eight ounces per week for several 
months, birth weight being doubled at five months and trebled at 
fifteen. If the indicated weekly gain is lacking, the mother's milk 
is deficient in nutrition, and other methods of feeding must be 
adopted. 

Mixed Nursing. — When the mother is able to nurse only par- 
tially, the quantity can be supplemented by occasional substitute 
feeding, not restricted as customary to the night, but either fol- 




FlG. 61.— Murphy Bandage Applied with Binder. 



lowing each nursing or limited to two or three full allowances dur- 
ing the twenty-four hours. 

Wet-Nursing. — If the mother's milk fails from the beginning 
or after a few days, a wet-nurse may be employed, though this 
method of substitute feeding is open to many objections and is too 
expensive for the ordinary family. The foster-mother should be 
a multipara, and her child of the same age or nearly that of the 
stranger. She must not be pregnant and preferably not menstru- 
ating, but in perfect health, physically and mentally, with well- 
developed breasts and prominent nipples, the best test of her fit- 
ness for the position being the condition of her own child. 



182 



THE PRINCIPLES OF OBSTETRICS. 



Artificial Feeding. — The only practicable substitute for human 
milk is cow's milk, between which there are important differences, 
as shown by the following comparative analysis : 

Human milk. Cow's milk. 

Fat 4.0 percent. 4.0 percent. 

Sugar 7.0 " 3.5 

Proteids 1.5 " 3.5 

Ash 0.1 " 0.52 

As is evident from the table, the principal differences are in 
the sugar and proteids, with the latter most important, because, 
being composed largely of casein, it is not adapted to the child's 
feeble digestion and requires decided modification for that purpose. 
Breast milk is secreted practically sterile ; cow's milk, particularly 
in the summer, is infected with various pathogenic and non- 
pathogenic germs, derived from the manner of milking, from un- 
clean receptacles, and directly from the atmosphere. To adapt 
cow's milk to infants' uses, it must be made alkaline, sterilized, the 
casein diluted, and the sugar increased. 

Daily Amount Required during First Year. — The quantity re- 
quired daily may be estimated by the recognized capacity of the 
ordinary child's stomach, which during the first month is one-one- 
hundredth of its body weight, and is shown in the following table : 



Age. 


Interval. 
Hours. 


Number of 

feedings in 

twenty-four 

hours. 


Amount in 

each feeding. 

Ounces. 


Amount in 

twenty-four 

hours. 

Ounces. 


First week 


2 
2 

2^ 

2^-3 
3 
3 


10 
IO 

s 

6 
6 

5 


I 

i l / 2 -2 l A 

2^-3^ 

4-5 

6 

8 


IO 


One to six weeks 

Six to twelve weeks. . . 
Three to six months . . 
Six to nine months . . . 
Nine to twelve months 


15-24 
20-28 
24-33 

36 

40 



Preparation of Cow's Milk. — Among the many formulas for 
the preparation of cow's milk, Hirst suggests the following: Milk 
for one bottle, 3 iv. ; boiled water, 3 v. ; cream, 3 i. ; lime water, 
3 i. ; milk sugar, gr. xx. (or half as much cane sugar). 

Boiling cow's milk destroys to a large extent its nutritive 
powers, and it is sufficiently sterilized by Pasteurizing, or heating 



NURSING AND SUBSTITUTE FEEDING. 183 

to 1 70 ° F. Six bottles should be prepared at once, in each of 
which put the desired amount for a single feeding, close with dry 
baked absorbent cotton, place in an Arnold's sterilizer, heat to 
1 70 F., cover with the hood, remove from the stove after twenty 
minutes, and cool in a refrigerator. Draw a sterilized nipple over 
each bottle when about to use, previously warming the bottle and 
its contents in a basin of hot water. 

In the absence of Arnold's sterilizer, the bottles when filled 
may be put into a tin pail half filled with water not quite boiling, 
allowed to stand upon the back of the stove for thirty minutes 
without boiling, and cooled as directed. 

Percentage Feeding. — The recent method of substitute feeding 
by the "percentage system," while open to the theoretical objec- 
tion that as prepared outside the laboratory in the home the pro- 
portions of ingredients are approximate rather than absolute, is a 
decided advance upon former processes. The underlying princi- 
ple is, instead of treating all forms of milk indigestion in the same 
manner, by simply diluting the food and thus reducing the pro- 
portion of all the elements, to reduce only that one which is caus- 
ing the trouble. For this reason and because no expensive ap- 
paratus is necessary, while the food can easily be gotten ready at 
home by the mother or untrained nurse, it is peculiarly adapted 
for general acceptance. 

The rule should be to begin with low proportions of fat and 
especially of proteids, and increase as the child becomes accus- 
tomed to them. For the first three months the ratio of fat to 
proteids should be that of breast milk, 3 to 1, for the third to 
tenth month 2 to 1, and afterward both should be equal. The 
quantity to be prepared at one time is based upon a scale of twenty 
ounces, it being more easy to calculate in twentieths than in six- 
teenths. A quart jar filled with fresh milk is placed in cold water 
or upon ice for four hours, when the upper third (about ten 
ounces) will contain nearly all the cream and assay twelve per 
cent fat. Ordinary milk bottled at the dairy, when supplied by 
the family milkman, has usually creamed to the same amount, the 
line of separation between upper milk and lower showing clearly. 

Fat is increased by using "top milk" alone or ordinary un- 
creamed (four per cent) milk with top milk (twelve per cent) ; 



184 



77//: PRINCIPLES OF OBSTETRICS. 



sugar by adding one ounce by weight (five per cent) (two and 
one half tablespoonfuls by measure) of milk sugar or half that 
quantity of white granulated cane sugar, one ounce (five per cent) 
of lime water producing the desired alkalinity. The proteids are 
diluted by water, plain or boiled, barley water, whey, or dextrin- 



WHDLE MILK 

C0KIAJH5 



fFAT 5UEAR PRQTE1D5 

3% 4% 3% 

U -to t. 

5* SZ 4% DISTRIBUTION OF FAT IHQTIT. 

FAT AND PROTEIDS ARE NEARLY 80TTLE0F4*.M!LK.EACH QZ. 
,E5UALEXI£PTWYERYRJCHMILK5 REMOVED WITH DIPPER 




FAT SUGAR 

,„ ,4.51=5.5% 4% 
TDPIGDZS. 6.51.7.5K 4% 

CONTAIN ABOUT s.St. 15% 4% 



PRDTEIDS 

3% 



SKIM MILK 

CONTAINS 



FAT 5UGAR PROTEIDS 

.5UL55v 4te5% 3lo4H 



_ 



:\X;\-\->i:-\-N.' - Sx\-^^v 




Fig. 62. 



-Quart Bottle of Milk Read}* for Use, with Dipper. 



ized gruel, the last two preventing coagulation of the casein into 
tough curds in the infant's stomach. 

How to Make Whey.— Put one pint of fresh cool milk into a 
clean saucepan and heat it lukewarm (not over ioo c F.) ; then 
add two teaspoonfuls of Fairchild's essence of pepsin, and stir 
just enough to mix; let it stand until firmly jellied, then beat up 



XUBSIXG AND SUBSTITUTE FEEDIXG. 



185 



well with a fork; now strain, and the whey (liquid part) is ready 
for use. Keep in a bottle on ice, or in a very cold place. 

It contains 0.22 per cent of fat, four per cent of sugar, and 
about one per cent of proteids, is easily digested, and coagulates 
into fine curds in the stomach. Before mixing with " top milk " 
it should be heated to 150 F. to stop the action of the pepsin, 
which will curdle the top milk also. 

Dextrinized Gruel. — This is prepared by boiling for twenty 
minutes in one pint of water one tablespoonful of barley, wheat, 
or rice flour, previously rubbed into a paste with cold water. Af- 
ter cooling to ioo° F., a teaspoonful of diastase (Forbes) or cereo 
is added, and the whole allowed to stand for twenty minutes. 

The practical application of this method is based upon the fol- 
lowing formulas, quoted from the article referred to in the foot- 
note.* 

Series A. — Ratio of fat to proteids, 3 to 1. 

Primary formula: Ten-per-cent milk, fat 10, sugar 4.3, pro- 
teids 3.3 per cent. Obtained (1) as upper one-third of bottled 
milk, or (2) equal parts of milk (four per cent) and cream (six- 
teen per cent). 

Derived Formulas Giving Quantities for Twenty-Ounce Mixtures. 
(Milk sugar, 1 oz. ; lime water, 1 oz. ; water, q. s. to 20 oz.) 





Fat. 


Sugar. 


Proteids. 




Per cent. 


Per cent. 


Per cent. 


I. With 1 ounce of 10-per-cent milk. . .. 


0.50 


5.20 


O.17 


II. With 2 ounces of 10-per-cent milk. . . 


I. OO 


5-40 


•33 


III. With 3 ounces of 10-per-cent milk. . . 


1.50 


5.60 


• 50 


IV. With 4 ounces of 10-per-cent milk. . . 


2.00 


5.S5 


.66 


A'. With 5 ounces of 10-per-cent milk. . . 


2.50 


6.05 


.83 


VI. With 6 ounces of 10-per cent milk. . . 


3.00 


6.25 


1. 00 


VII. With 7 ounces of 10-per-cent milk. . . 


3- SO 


6.50 


1.20 



Series B. — Ratio of fat to proteids, 2 to 1. 

Primary formula: Seven-per-cent milk, fat 7, sugar 4.4, pro- 
teids 3.4 per cent. Obtained (1) by using the upper one-half of 
bottled milk, or (2) by using three parts milk (four per cent) 
and one part cream (sixteen per cent). 



*Holt: "General Principles of Infant Feeding," etc. New York 
Medical Journal, January 12th, igoi. 



186 



THE PRINCIPLES OF OBSTETRICS. 



Derived Formulas Giving Quantities for Twenty-Ounce Mixtures. 
(Milk sugar, i oz. ; lime water, i oz. ; water, q. s. to 20 oz.) 







Fat. 


Sugar. 


Proteids. 






Per cent. 


Per cent. 


Per cent. 


I. With 


1 ounce of 7-per-cent milk . . . 


0-35 


5-20 


O.17 


II. With 


2 ounces of 7-per-cent milk . . 


.70 


5-40 


■35 


III. With 


3 ounces of 7-per-cent milk . . 


I.05 


5.60 


• 52 


IV. With 


4 ounces of 7-per-cent milk . . 


I.40 


5.8o 


.70 


V. With 


5 ounces of 7-per-cent milk . . 


i-75 


6.00 


.87 


VI. With 


6 ounces of 7-per-cent milk . . 


2.10 


6.20 


1.05 


VII. With 


7 ounces of 7 per-cent milk . . 


2-45 


6. +5 


1.22 


VIII. With 


8 ounces of 7-per-cent milk . . 


2.80 


6.70 


1.40 


IX. With 


9 ounces of 7-per-cent milk . . 


3-T5 


6.90 


i-55 


X. With 


10 ounces of 7-per.centmilk . . 


3-50 


7.10 


i-75 


XI. With 


n ounces of 7-per-cent milk .. 


3.85 


7-30 


i-93 


XII. With 


12 ounces of 7-per-cent milk . . 


4-i5 


7.50 


2.07 



Series C. — Ratio of fat to proteids, 8 to 7. 
Primary formula: Plain milk, fat 4, sugar 4.5, proteids 3.5 
per cent. 

Derived Formulas Giving Quantities for Twenty-Ounce Mixtures. 
(Milk sugar, 1 oz. ; lime water, 1 oz. ; water, q. s. to 20 oz. ) 





Fat. 


Sugar. 


Proteids. 




Per cent. 


Per cent. 


Per cent. 


I. With 2 ounces of 4-per-cent milk 


O.40 


5.40 


0-35 


II. With 4 ounces of 4-per-cent milk . . 


.80 


5.8o 


.70 


III. With 6 ounces of 4-per-cent milk... 


1.20 


6.20 


I.05 


IV. With 3 ounces of 4-per-cent milk... 


1.50 


6.70 


I.40 


V. With 10 ounces of 4-per-cent milk... 


2.00 


7.10 


i-75 


VI. With 12 ounces of 4-per-cent milk... 


2.40 


7.60 


2.10 


VII. With 14 ounces of 4-per-cent milk... 


2.80 


8.10 


2.45 


VIII. With 16 ounces of 4-per-cent milk... 


3.20 


8.50 


2.80 



For the new-born child, begin with No. II. of Series A, and 
if well assimilated pass gradually to No. VI. (fat 3 per cent, 
sugar 6 per cent, proteids 1 per cent) up to the sixth or seventh 
week. Then change to Series B, beginning with No. VII. or No. 
VIII. (fat to proteids, 2 to 1), increasing slowly up to the ninth 
month with Nos. X. or XL, the quantity being enlarged to the 
needs of the child. The proteids are increased in Series C, which 
should begin with Nos. VI. to VIII., gradually changing to whole 



NURSING AND SUBSTITUTE FEEDING. 187 

milk. No formula can be followed absolutely, but each is simply 
a general guide for those proportions which succeed with children 
of normal digestion. 

Home Modification of Percentage Feeding. — For the first 
month this method can be simplified at home as follows: : Have 
the milk supplied in two one-pint bottles, and let one cream as de- 
scribed. Dissolve two tablespoonfuls of milk sugar (or one table- 
spoonful of cane sugar) and a pinch of salt in one pint of boiled 
or plain water, add two tablespoonfuls (one ounce) each of "top 
milk " and whole uncreamed milk (the latter taken from the sec- 
ond bottle which has been thoroughly stirred), and divide among 
six or eight bottles. Cork with absorbent cotton, and place in 
a pail half filled with very hot water, or at a temperature just be- 
low boiling, put the pail of bottles upon the back of the stove for 
half an hour, remove and cool in a suitable place. Before using 
heat a single bottle in a basin of warm water, testing the tempera- 
ture of the contents not by tasting but by the hand upon the out- 
side, draw on the nipple, and pour away any portion remaining 
after the child is satisfied. The fat is increased by taking more 
"top milk," the proteids by lessening the quantity of the diluent, 
but the gross amount prepared should be constant at one pint, i.e., 
whatever number of ounces of milk and cream is added the same 
amount of water is omitted. 

While these proportions are not exactly those of Holt, the 
" home-modification method " has been almost universally success- 
ful in the practice of the author. 

Practical Hints for Assimilation of Substitute Feeding. — The 
following suggestions for varying the proportions of any ingredient 
in cow's milk maybe offered: Early vomiting of sour coagula 
indicates too much cream (fat) — decrease the quantity of "top 
milk " ; green curdy stools mean too much casein — add more dilu- 
ent ; colic an hour or more after feeding, too much fat and casein 
— add more diluent and sometimes less sugar ; diarrhoea, too much 
cream ; constipation, not enough cream or water. In normal diges- 
tion of breast milk the stools are three to four in twenty-four 
hours, soft, smooth, yellow, and not offensive; with cow's milk the 
stools are larger and liable to contain undigested lumps of curd. 

Incubator for Premature Infants. — The chances of life for a 



188 



THE PRINCIPLES OF OBSTETRICS. 



premature infant are much improved if it is placed immediately 
after birth in an incubator or couveuse, where it should live as 
many weeks as it is premature. Any one of the commercial ap- 
paratuses may be employed (Holt, Rotch, Auvard, etc.), or one 
can be extemporized from an ordinary clothes basket, heated by 
bottles of hot water. A serviceable incubator can easily and 
cheaply be made from an ordinary wooden box, 18 by 24 by 10 
inches, and covered with a pane of glass. Heat is provided by a 




Fig. 63.— Home-Made Incubator ; front removed to show the interior. 



common kerosene lamp, whose chimney passes into a pipe with 
an elbow (ordinary small -sized tin gutter-pipe answering every 
purpose), and fastened inside the box in such a manner that the 
short arm is fixed to one end and the long arm to the upper edge, 
ventilated by holes at the opposite end and side, and moisture pro- 
vided by a wet sponge hung inside. For the first few days the 
temperature should be kept between 98 and 95 F., and gradually 
lowered to 85 F. as the child's vitality increases. The first wash- 
ing must be omitted, and instead it should be well rubbed in clean 



NURSING AND SUBSTITUTE FEEDING 



189 




lard or cacao butter, enveloped in cotton batting, the usual outer 
dress being put on for appearance' sake. Feeding should be 
through a medicine dropper, one drachm every hour for the first 
twenty-four or forty-eight hours, increasing up to 
one-half ounce every two hours for a seven-months 
child and three-quarters to one ounce for one of 
eight months. The food should be breast milk if 
possible, or as a substitute whey or a five-per-cent 
solution of milk sugar. The box must be kept 
scrupulously clean by a daily wash with bichloride, 
but the child should not be taken out except when 
bathed or fed. 

kGavage. — -Forced feeding by means of a tube 
\ passed through the mouth or nose into the stomach 
_ """* is useful in premature or very feeble full-term in- 
fants, especially those reared in an incubator. A 
soft-rubber catheter, No. 12 or No. 16, with a small glass funnel 
attached to it by tubing, is passed quickly into the stomach, the 
funnel raised, and food poured into it, and the catheter immedi- 
ately withdrawn. Afterward the child should lie 
quietly upon its back, the feeding being repeated if 
the first is regurgitated, and the intervals between 
successive feedings should be longer than for 
nursing. 

Nursing Bottles and Nipples. — The simpler the 
apparatus for substitute-feeding the better. The 
nursing bottle should be round and tubular, free 
from angles in which sour milk may collect, and 
from six to eight ounces in capacity. The best 
rubber nipple is a simple cone, not too flexible, with 
openings small enough to retain the food except 
when in actual use. If the contents flow out when 
the bottle is inverted, the orifices in the nipple are 
too large, food is supplied too quickly to the child, 
and indigestion is likely. The nipple should be at- 
tached directly to the bottle without the intervention of tubing, 
which is almost impossible to cleanse, and all bottles and nip- 
ples should be scalded before using, being kept submerged mean- 




FiG. 65. — Milk 
Bottle. 



190 



THE PRINCIPLES OF OBSTETRICS. 



time in a weak solution of bicarbonate of sodium (common saler- 
atus) or boric acid. 

Breast Pumps. — The ordinary commercial breast pump is 
made incorrectly, the bell being too small to accommodate the 




Fig. 66. — Breast Pump. The bulb easily cleansed owing to shape. 



nipple when swollen under the suction of the rubber bulb, and the 
glass bulb cannot be cleansed readily. An improved article is 
shown in the figure, reproduced from Chapin's " Infant Feeding." 



PART VI. 
PATHOLOGY OF LABOR. 



CHAPTER I. 

IRREGULARITIES IN MECHANISM OF LABOR. 

I. THE POWERS, 

The amount of expulsive force used in childbirth is one of the 
factors which affects its duration, and results in two conditions, 
precipitate labor and protracted labor, their line of demarcation 
being relative rather than absolute. 

A. Extreme Power. — Precipitate labor. When labor is rapid 
enough to imperil the life of either mother or child, as, for in- 
stance, if completed in a single pain while the woman is sitting 
upon a commode or standing, it is called precipitate. The cause is 
too great expulsive force, either of the uterus or of the abdominal 
muscles, or both combined, and lack of resistance between the pas- 
sages and passengers, such as occurs with a small child in a large 
pelvis or in relaxed tissues of the canal. 

Dangers. — Theoretically, the dangers to the mother in this 
variety of labor are lacerations of the cervix or perineum, prema- 
ture detachment of placenta, post-partum hemorrhage, and shock ; 
to the child, rupture of the cord, asphyxia, and injury from falling. 
Practically, these dangers are exaggerated, and precipitate labor 
is not usually specially hazardous. 

Treatment. — If the physician can be in attendance, hasty 
expulsion may be retarded by confining the patient strictly 
to bed, use of anaesthesia to prevent straining and bearing 
down, and direct pressure in the vagina against the descending 
part. 

E. Deficient Power. — Protracted or tedious labor. Delivery 

may be prolonged beyond the classical period by simply feeble, 

inefficient contractions (inertia uteri), or by irregularities in the 

passages and passengers. Delay in the first stage largely results 

13 193 



194 THE PRINCIPLES OF OBSTETRICS. 

from powerless contractions ("apathy of the uterus"), i.e., from 
inability of the expelling forces to overcome the resistance of the 
cervical ring, and in the second stage is usually mechanical, the 
condition being then called obstructed labor. 

Etiology. — The causes assigned for protracted labor are: (i) 
Lack of power; (2) irregularities of the passages; and (3) of the 
passengers. 

( 1 ) Lack of power results from arrested development of the 
uterus (infantile or bifid uterus, etc.), weakened innervation of 
uterine muscle from frequent and quickly repeated gestations, 
multiple pregnancies, and hydramnios ; fever, ante-partum hemor- 
rhage, pendulous abdomen, premature rupture of the membranes 
(dry birth), mere general fatigue so often seen in primiparae, 
mental impressions like fright, anxiety, disappointment, and phys- 
ical exhaustion. 

(2) Irregularities of the passages. New growths of the 
uterus and other pelvic organs, displacements of and inflam- 
matory adhesions about the uterus, and distended bladder and 
rectum. 

(3) Irregularities of the passengers. Excessive size of the 
child, monstrosities, malpresentations, or, speaking generally, any 
disproportion between the child and canal. 

Varieties of Inertia. — Three varieties of irregularity in expul- 
sive force are recognized : ( 1 ) Primary uterine inertia, when con- 
tractions are feeble from the beginning with resulting protracted 
labor; (2) secondary uterine inertia, when the uterus is exhausted 
by sharp, frequent, ineffective pains without corresponding prog- 
ress; and (3) obstructed labor, when the act is prevented by me- 
chanical obstruction. 

Differential Symptoms. — 1. Primary inertia. Contractions are 
short, feeble, and recur at long intervals, the uterus being at the 
same time softer than normal and not tender to pressure ; there 
is little or no progress in either dilatation or descent, suffering is 
inconsiderable, temperature normal, and pulse but slightly in- 
creased. 

2 and 3. The following table, from "Difficult Labor," by Her- 
man, presents the differential symptoms of the second and third 
classes : 



IRBEGUIABITIES IN MECHANISM OF LABOB. 195 



Secondary Uterine Inertia. 



Obstructed Labor. 



A. The Patienf s General Condition. 



Expression placid : at most show- 
ing signs of fatigue : not over- 
anxious. 

Pulse not over ioo. 

Breathing not hurried. 



Expression of face tired and anx- 
ious. 

Pulse small and quick : generally 

1 20 or over. 
Breathing hurried in proportion to 

pulse. 



Uterus not tender. 

Outline and limbs of child can be 
felt distinctly, and child moved 
about. 



B. Abdominal Examination. 

Uterus tender if condition has 

lasted long. 
Outline of child cannot be felt, but 

only that of hard and immovable 

uterus : limbs of child cannot be 

felt. 



C. Vaginal Examination. 



Presenting part can be pushed up 

easily. 
Caput succedaneum small, so that 

sutures can be felt. 

Little or no swelling of vagina and 

vulva. 



Presenting part cannot be pushed 
up. 

If head is in pelvic cavity, large ca- 
put succedaneum, so that sutures 
cannot be felt. 

If head is in cavity, vagina and 
vulva are swollen. 



Prognosis. — During the first stage, long-continued pain with- 
out the mental stimulus of conscious progress induces loss of 
vitality and liability to septic infection, while loss of sleep and food 
results in general exhaustion and heightened temperature. In 
the second stage, danger to the mother is relative to the degree 
of either her mental and physical suffering or extent of injury to 
the canal from impaction of the presenting part and liability of 
subsequent inflammatory changes, like sloughing of the vagina, 
vesico-vaginal and recto-vaginal fistulae. Dangers to the child are 
asphyxiation from disturbance of placental circulation and injuries 
received during delivery (intracranial hemorrhage, fractures, etc.). 

Treatment. — Since protracted labor depends upon many causes, 
treatment must evidently vary accordingly. When due to simple 
inertia no particular treatment is required during the first stage 
so long as the patient's condition is but little affected, sufficient 



196 THE PRINCIPLES OF OBSTETRICS. 

sleep and nourishment taken, and the membranes are unruptured. 
Indirect stimulants to arouse greater uterine action are walking 
about the room, hot vaginal douches repeated every half-hour, sitz 
baths, hypodermics of strychnine, one-thirtieth grain every three 
or four hours, and quinine, ten grains, the latter exceptionally 
causing post-partum hemorrhage. Direct uterine stimulants are 
the introduction of a sterilized bougie high up into the cavity, hy- 
drostatic dilators like Champetier de Ribes' and Barnes' bags, the 
last mentioned frequently disappointing because of the difficulty of 
insertion, failure in dilating power, liability of bursting, and prob- 
ability of displacing the presenting part. Manual dilatation by 
the Edgar or Harris method (page 260) is more under the im- 
mediate control of the operator, and therefore safer than any form 
of instrumental interference. 

When delay is due to exhaustion from long -continued suffer- 
ing, analgesics are required, chloral in fifteen-grain doses repeated 
every hour for four doses ; morphine hypodermically, one-fourth 
grain; or application of cocaine in ten-per-cent solution to the 
cervix. Anaesthesia is very rarely indicated. The best authori- 
ties agree that ergot, from its well-known danger in causing tonic 
contractions, is unsafe in tedious labor and ought not to be used 
in this complication. Alcohol, in the form of champagne, whis- 
key, etc., is occasionally serviceable, but uncertain in results. In 
secondary inertia, do not deliver, but wait; in obstructed labor, 
deliver at once. 

If the uterine forces are obviously inefficient, forceps is indi- 
cated, and though no absolute rule for the time of its application 
can be made, it is customary to direct its use when there has been 
no progress for two hours in the first stage, and for one-half to 
one hour when the head is low in the canal. 

II. THE PASSAGES. 

A. Irregularities of the Hard Parts. B. Of the Soft 

Parts. 

A. Deformities of the Pelvis. — Frequency. — It was formerly 
thought that deformed pelves were rather unusual in America, 
but recent investigations have shown them to be much more fre- 



IBBEGULABITIES IX MECHANISM OF LABOR. 197 

quent than has been believed. Most cases occur in this country 
in emigrants from Europe, but Williams, of Johns Hopkins Uni- 
versity, has demonstrated that the anomaly is not so very infre- 
quent among native-born American women. The Boston Lying- 
in Hospital reports pelvic deformity in two per cent of native-born 
puerpera and six per cent of foreign-born. Williams estimates 
seven per cent of deformity in white women of American cities, 
and that it is nearly three times more frequent in black women 
than in white. Probably distortion great enough to imperil labor 
is rare in American private practice, and statistics of hospitals are 
taken largely from women of the foreign peasant class. Pelvic 




FIG. 67.— Collyer's Pelvimeter. 

contraction to some degree apparently exists in from ten to fifteen 
per cent of all child-bearing women. 

Classification. — Pelvic deformities are classified according to 
differences either in their shape and size, or on a scale of oversize, 
undersize, and inclination. Hirst groups them: (1) According to 
faulty development ; (2) to disease of the pelvic bones ; (3) of their 
articulations ; (4) of the superimposed skeleton ; and (5) of the ad- 
jacent skeleton. Jewett says that the most frequent in order are 
simple flattening, general contraction, kyphosis, and scoliosis. 
Obstruction of the bony canal results from pelvic fractures (cal- 
lus and vicious union) and new growths of various forms and 
character. 

General Diagnosis. — Though there are many exceptions, pelvic 



198 



THE PRINCIPLED OF OBtiTETRK s. 



deformity is often indicated by a history of severe constitutional 
disease during infancy or childhood, gait on walking, appearance 
of the patient, and possibly from examination of the head of one 
of her children. It is probable if she had symptoms of rickets in 
early life (enlargements of the joints, sweating at night, late teeth- 
ing, curvature of the spine or long bones, pendulous abdomen) and 
there has been previous dystocia. Diagnosis is established by 
palpation and pelvimetry of the exterior and interior of the pelvis. 
Pelvimetry. — Various instruments have been devised for meas- 
uring the pelvis, of which that of Collyer can be recommended. 




Fig. 68.— Pelvimetry ; Measuring the Crestal Diameters. 



The principal external diameters are those of the false pelvis, in- 
ter spinous, intercrestal, and antero-posterior (external conjugate 
or Baudelocque's), internally the true and diagonal conjugate and 
those of the outlet. Have the woman lie upon her back, with all 
clothing removed, and covered with a sheet. Hold each arm of 
the pelvimeter so that the finger tip projects slightly beyond the 



IRREGULARITIES IN MECHANISM OF LABOR. 199 

knob, move the finger and knobs together to and fro until the 
widest distance is obtained, and read the measure upon the scale. 
In well-built women the crestal diameters are 10)2 inches (29 
cm.), the interspinous 9^ inches (26 cm.), and are valuable only 




Fig. 69.— Pelvimetry ; Measuring the External Conjugate Diameter. 



as corroborative of the internal ; but if both diameters are uniformly 
less than normal, transverse contraction of the interior is probable. 
To obtain the external conjugate, turn the woman upon the left 
side, slightly flex the thighs, and stand at the side facing her 
head. Find the depression below the spinous process of the last 



200 



THE PRINCIPLES OF OBSTETRICS. 



lumbar vertebra by passing the finger along the processes until no 
more are evident, and, after placing one knob of the instrument in 
this depression, hold it there. Put the other knob upon the mons 
veneris, a little below its upper border, and the scale should indi- 
cate at least y% inches (19 cm.). If the distance is more than 
this, contraction is rare ; if it is less, it is present to greater or 




Fig. 



-Mode of Measuring the Diagonal Conjugate. (Herman.) 



less amount. These measures may also be taken with the patient 
in the standing position, as represented in the illustrations. 

In measuring the external conjugate the method suggested by 
Kelly may be used, but it is difficult unless the patient is of slight 
build, and impossible during pregnancy unless at a very early 
stage. Make deep palpation above the symphysis backward tow- 
ard the spine, feeling for the promontory with the tips of the ex- 
tended fingers. The anterior point is determined by pressing 
the middle finger of the free hand down behind the symphysis. 



IRREGULARITIES IX MECHANISM OF LABOR. 201 

An impression is made upon the outstretched hand at this point, 
and the distance from the tip of the finger to this mark is the 
measure of the true conjugate.* 

These external measures are merely approximate, those ob- 
tained by vaginal examination only being reliable. For internal 
pelvimetry, place the woman on the edge of the bed or table in the 
lithotomy position. Pass the index and middle fingers, well oiled, 
upward and inward into the vagina until the tip of the middle fin- 





FlG. 71.— Direct Pelvimetry ; measure- 
ment, four inches. (Herman.) 



FlG. 72. — Direct Pelvimetry ; measurement, 
three and one-half inches. (Herman). 



ger touches the promontory. Raise the examining hand until the 
web between the thumb and finger rests against the subpubic 
ligament ; mark with the finger nail of the other hand this point, 
withdraw both hands together, and measure the distance (Fig. 70, 
page 200). This is the diameter of the diagonal conjugate, from 
which the true conjugate is derived by deducting from one-half to 
two-thirds of an inch for the height of the symphysis. Ordinarily 
it is impossible to reach the promontory through the vagina in the 
normal pelvis. Hirst measures the true conjugate by a special 



* Kelly: "Gynecology," p. 



202 



THE PRINCIPLES OF OBSTETRICS. 



pelvimeter, taking the distance from the anterior surface of the 
symphysis to the promontory, then by a second instrument meas- 
uring" the thickness of the pubis, and subtracting this measure 
from the other. 

Another method of measuring the true conjugate is first to 
etherize the patient, who is placed on her left side upon the edge 
of the table, then to pass the whole hand into the vagina, the little 
finger resting upon the symphysis and the index finger against the 




Fig. 73. — Direct Pelvimetry ; measurement, 
three and a quarter inches. (Herman. 1 



Fig. 74. — Direct Pelvimetry; measure- 
ment, three inches. (Herman.) 



promontory, and measure the distance across the number of fingers 
which can be introduced at the same time. 

Transverse and oblique diameters of the outlet can be taken 
only approximately by external pelvimetry. 

Digital measurement of the pelvic interior is practicable at all 
periods of gestation except when the head or other presenting part 
is in the cavity ; manual pelvimetry can be used only after delivery 
or during some operation requiring the introduction of the hand, 
and therefore not universally serviceable. Though pelvimetry is 
often disappointing from its inherent difficulties, it is of great 
value in assisting to diagnose pelvic irregularities, and becomes 
more so with practice. 



IRREGULARITIES IN MECHAXISM OF LABOR. 



203 



Palpation of the Pelvic Interior. — 

Palpation of the pelvic cavity indi- 
cates the size and shape of its walls, 
depth and direction of its canal, con- 
tour of the hollow of the sacrum, dis- 
tance between the ischial tuberos- 
ities, variation of one wall from the 
other, and presence of any pathologi- 
cal growth. The antero-posterior di- 
ameter of the outlet is not invariable, 
since it is enlarged at delivery by 
pushing backward of the coccyx, and 
measured by passing the two first 
fingers into the vagina and finding 
the distance between the lower edge 
of the symphysis and tip of the 
sacrum. The transverse diameter is 
constant, and easily measured by a 
pelvimeter, or by placing the thumbs firmly upon the tuberosities 
of the ischia and having a second person measure the interval. 




Fig. 75. — Direct Pelvimetry; 
measurement, two and one-half 
inches. (Herman.) 



CHAPTER II. 
DEFORMITY OF THE PELVIS. 

SIMPLE FLAT PELVIS. 

This is the most common pelvic irregularity, and is quite often 
without an external manifestation. 

Characteristics. — The antero-posterior diameter is contracted 
throughout the entire canal by projection downward and forward 
into it of the sacrum, which is relatively smaller than normal. It 




Fig. 76.— Diagram of the Generally-Contracted Flat non-Rachitic Pelvis. Black 
line, normal pelvis ; dotted line, contracted pelvis ; B, sacral concavity at brim ; 
B, B, sacrum ; C\ C\ transverse diameter ; D, D, ilio-pectineal eminence ; A, 
symphysis. (Herman.) 

is simply an antero-posterior flattening, but the true conjugate is 
seldom less than three inches. The external diameters, spines 
and crests, and internal transverse and obliques, are normal or 
slightly increased, the circumference being diminished or natural. 
Mechanism of Labor in Flat Pelves. — Irregular presentations 
and prolapse of the cord are frequent ; the head is arrested at the 

204 



DEFORMITY OF THE PELVIS. 205 

inlet; it engages at the superior strait with the long axis (occipito- 
frontal) in the transverse pelvic diameter midway between flexion 
and extension; moulding is delayed. After passing the brim the 
cephalic movements are similar to those in the normal pelvis. 
There is likely to be a depression upon the child's skull from press- 
ure against the promontory. 

Etiology. — The larger number are probably congenital and in- 
herited, it being often found in sisters. Other causes assigned for 
it are early hard physical work, particularly the carrying of heavy 
burdens in childhood, rachitis, and a trunk too weighty for the 
pelvic ligaments to support. 

Treatment. — This necessarily depends upon the amount of de- 
formity, and the various methods are summarized as follows : 

True conjugate above y/ 2 inches (9 cm.): 1. Spontaneous de- 
livery of a living child is possible, especially if normal in size or 
below the average ; the first stage is retarded from lack of pressure 
of the head or presenting part upon the uterine outlet ; malposi- 
tions should be corrected early, and membranes preserved as long 
as possible. Natural forces being powerless, delivery may be 
effected by : 

2. Forceps, if the child is viable and living and the head is en- 
gaged. Prognosis is grave for both mother and child, depending 
upon the amount of the distortion and the character of the oper- 
ation required, and is much worse than in normal pelves. 

3. Podalic version, if the child is viable and living and the head 
unengaged. A general rule for choice of the two operations is 
forceps for primiparae, in whom the canal is more resistant than 
in multiparas, for whom version on this account is preferable. 
Much also depends upon the habit of the individual operator, 
some being more dexterous with one method than the other. 

4. When the child is dead, forceps or version is indicated in 
lesser deformities, craniotomy in greater ones. 

5. The elective operation is induced labor at the eighth calen- 
dar month (thirty-sixth to thirty-eighth week), but unfortunately 
fetal mortality is high, being nearly thirty-three per cent. 

True conjugate 2% to y/ 2 inches (7 to 9 cm.): The elective 
operation is either Caesarean section or symphyseotomy, the latter 
being chosen when the diameter is between three and three and 



206 



THE PRINCIPLES OF OBSTETRICS. 



one-third inches. If the child is dead or non-viable, podalic version 
or craniotomy ; but induced labor at the eighth month should be 
considered. 

True conjugate below 2^ inches: Caesarean section and hys- 
terectomy at term, or induced labor. 

The choice of operation depends largely upon the size of the 
passenger, a small child being sometimes safely delivered when 
one of normal size cannot be. Cases of lesser deformity are rarely 
detected until labor is in actual progress, when if the child is liv- 
ing forceps are required, and craniotomy when it is dead. 



JUSTO-MAJOR PELVIS. 

There is symmetrical enlargement in all diameters with the 
shape normal and the woman above the average stature. Labor is 




Fig. 77.— Justo-Minor Pelvis. (Herman.) 

usually precipitate, with the complications liable to that form of 
birth. Treatment is that for precipitate labor. 



JUSTO-MINOR PELVIS. 

The general contour is normal but symmetrically contracted. 
Three divisions are made : (1) " Juvenile," bones small and slender; 
(2) "masculine," bones heavy, large, and thick; and (3) "dwarf" 
(pelvis nana), diminutive pelvis, in which the individual bones are 



DEFORMITY OF THE FEE VIS. 207 

joined by cartilage as in the infant. This variety is said to be 
quite common in America, being also associated with simple flat 
pelvis, generally contracted and transversely contracted pelvis. 
The woman is ordinarily undersized, but the deformity may be 
present in those of average figure. 

Etiology. — The cause is arrested development ; contraction is 
never extreme, the conjugate being rarely below 3^ inches 
(9 cm.). 

Diagnosis. — Pelvimetry shows that all diameters are equally 
lessened, except the true conjugate, which is frequently enlarged. 

Influence upon Labor. — The head is well flexed, presenting in 
either the transverse axis or more often the oblique. Breech cases 
are particularly bad on account of the difficulty in delivering the 
arms and after-coming head. There is great probability of rup- 
turing the pelvic articulations during extraction, and, Hirst says, 
of eclampsia. 

Treatment. — The same as in simple flat pelvis. 

GENERALLY FLAT CONTRACTED NON-RACHITIC PELVIS. 

This variety is a combination of the flat and generally con- 
tracted pelvis, and is comparatively rare. 

Characteristics. — All diameters are lessened, the true conju- 
gate especially. The sacrum is small, the promontory high but 
not projecting, deformity being due to lack of development of the 
innominates and wings of the sacrum. 

Etiology. — Arrested development, heredity, and too early walk- 
ing or long standing in childhood. 

Treatment. — Same as in simple flat pelvis. 

RARE FORMS OF CONTRACTED PELVIS. 

Male Pelvis. Fetal or Funnel-Shaped Pelvis — Deformity 
is due to contraction at the outlet from approximation of the spines 
of the ischia. The sacrum is long and straighter than normal, 
and the canal is lengthened. The so-called " male pelvis " results 
from narrowing of the angle of the pubic arch,, and is not uncom- 
mon. 



208 



THE PRINCIPLES OF OBSTETRICS. 



Diagnosis. — This is made from careful pelvimetry and palpa- 
tion of the canal. 

Rachitic or Kyphotic Pelvis. — The irregularity results from 
rickets, varying in its peculiarities according to the severity of the 
disease, and might be artificially produced by squeezing a pelvis 
together antero-posteriorly. The sacrum sinks deeply, and is un- 
naturally curved perpendicularly, the upper portion being tilted 




Fig. 78.— Kyphotic Pelvis. (After Barbour.) 



backward and the lower forward ; the innominates bend outward 
at the acetabula, causing an increase of the transverse diameter, 
the other diameters being generally normal. The brim is kidney- 
shaped, and if the symphysis is also displaced inward it forms a 
figure of eight. The crests rotate outward, giving the diagnostic 
character of the deformity to the false pelvis, the spinous diam- 



DEFORMITY OF THE PELVIS. 



209 



eters being equal or larger than the crestal, though normally they 
should be smaller. As a whole the pelvis is shallow, the inlet 




FIG. 79. -Skolio-Rachitic Pelvis. (After A. Martin.) (Page 210.) 

narrowed from before backward, and the inclination greater than 
natural, so that the external genitals are displaced backward. The 



~^c 




Fig. 80. — Diagram of Brim of Skolio-Rachitic Pelvis. Continuous line, normal 
pelvis ; dotted line, deformed pelvis ; B, B, sacro-iliac synchondroses ; E, centre 
of sacrum in plane of brim ; C, C\ transverse diameter ; Z>, D, pectineal eminences ; 
A, symphysis pubis. (Herman.) 

pubic arch is widened by separation of the tuberosities of the 
ischia, which also increases the transverse diameter of the outlet. 
14 



210 



THE PRIXC1PLE8 OF OBSTETRICS. 



Other unusual varieties of this deformity are the scolio-rachitic 
pelvis, due to lateral curvature of the spine, one half being- pressed 
in more than the other, making an oblique irregularity ; pseudo- 




FlG. 



Pseudo-Osteomalacic Rachitic Pelvis. (After Naegele.) 



malachia or pseudo-malacosteon, when pressure is bilateral, result- 
ing in extreme distortion similar to that of osteomalacia ; equally 
contracted rachitic pelvis, due to arrested development, without 
decided change in shape of pelvis or canal. 

Diagnosis. — This is made from the equality between the diam- 
eters of the crests and spines, the history of rickets in childhood, 




Fig. 82. — Transversely-Contracted Pelvis of Robert. (Herman.) 

and the symptoms of that disease elsewhere in the body. Ordi- 
narily there are other of its well-known signs in the configuration 



DEFORMITY OF THE PELVIS. 



211 



of the individual, in the curvature of the spine (kyphosis or scoli- 
osis), the pendulous abdomen at term, dwarfed figure, etc. Pelvi- 
metry shows narrowing of the internal and external conjugate, 
the pelvic cavity is very shallow, the sacrum much curved, the 
promontory low down and often double, with the spinous and 
crestal diameters equal, as has been said. 

Influence upon Labor. — Practically similar to that of the simple 
flat pelvis. 

Roberts Pelvis. — In this, the rarest of all contracted pelves, 
there is entire or partial absence of both wings of the sacrum, the 




Fig. 83.— Obliquely-Contracted Pelvis of Naegele. (Herman.) 



posterior spinous processes of the ilia are nearly in apposition, the 
transverse diameters are very much diminished, and usually there 
is an associated ankylosis of the sacro-iliac articulations. Natural 
delivery is impossible. 

Naegele' s Pelvis. — Here there is entire or partial absence of 
one wing of the sacrum, ankylosis of the articulation of that side ; 
the sacrum and promontory are diverted toward the deformed 
half, which is smaller than normal, the opposite half being corre- 
spondingly enlarged. The brim is oblique and oval, with the 
symphysis not facing the promontory, the cavity converges at the 
outlet, and the pubic arch is irregularly contracted. 

Osteomalacic or Malacosteon Pelvis. — A form very rare in 



212 



THE PRINCIPLES OF OBSTETRICS. 



America, and due to disease and subsequent softening of the pel- 
vic bones (usually occurring during pregnancy), which bend in re- 
sponse to existing pressures. The sides of the pelvis are incur- 




FlG. 84. — Osteomalacic Pelvis. (Herman.) 



vated, decreasing the transverse diameters, giving a beak shape 
to the pubic portion of the brim, thus contracting and distorting 
the cavity in all of its diameters. The sacrum is convex both 




Fig. 



-Spondylolisthesis. (After Kilian.) 



perpendicularly and laterally, its lower third being sharply flexed, 
and the transverse diameter of the outlet widened. 

Spondylolisthetic Pelvis. — The last lumbar vertebra is dislo- 



DEFORMITY OF THE PELVIS. 



213 



cated upon the first sacral, causing great shortening of the antero- 
posterior diameter of the brim, and, from tilting forward of the 
coccyx, of the corresponding diameter of the outlet. Distortion of 
the cavity and outlet is great, usually requiring a capital opera- 
tion for delivery. This form of pelvis is very rare. 

Pelvic Deformity from Coxalgia. — When coxalgia (inflamma- 
tion of the hip bone) has existed in childhood, the pelvis is ordi- 
narily deformed from supporting the body upon the sound side dur- 
ing standing or walking, the unequal pressure pushing it toward 
the diseased side and 



resulting in a similar 



irregularity to that of 




FIG. 86.— Sacral Exostosis. (Herman.) 



the Naegele pelvis. Associated ankylosis of the hip-joint and 
inequality in the halves of the pelvis may cause great difficulty in 
delivery, especially in the use of forceps, the deformity being 
greater the earlier in life the disease appears. 

Tumors of the Pelvic Interior. — The cavity may be reduced by 
any form of pathological growth : exostoses, callus from old frac- 
tures, and vicious union, different varieties of cancer, and cysts. 
Csesarean section is quite often needed for delivery, and the prog- 
nosis for both mother and child is grave. 

In attempting to decide the possibility of delivery in contracted 
pelves, besides the use of pelvimetry and other methods of defining 



214 THE PRINCIPLES OF OBSTETRICS. 

the passage, an estimate should also be made of the size of the 
child's head. In suitable cases it may be feasible partially to 
measure it with a pelvimeter through the abdominal walls, but a 
more practicable way is to push the head into the pelvis as far as 
possible and test by vaginal examination the distance to which 
it descends. Unfortunately many of the slighter deformities are 
unrecognized until actual labor, when the difficulties of delivery 
are much increased and can be solved only at added risk to both 
mother and child. 

B. OF THE SOFT PARTS. 

Irregularities in Development of the Uterus. — When the foetus 
is in the embryonic stage, there may be arrest of development of 
the ducts of Miiller, which form by their union the uterus, and 
result in various malformations of that organ and complications in 
both pregnancy and childbirth. Entire failure of union results in 
a uterus didelphys ; if joined externally but separated internally, in 
a uterus bicornis duplex ; and if connected at the cervix but discon- 
nected above, in a uterus bicornis unicollis. If the two ducts are 
completely united but separated by a median partition, there being 
no external evidence of the deformity, the result is a uterus sep- 
tus ; when the septum continues through the entire length of the 
cavity, uterus septus duplex ; but if only partially, uterus subsep- 
tus. The fundus may also be deformed from the same cause, the 
uterus being then called cordiformis or incudiformis. 

Failure of union of the ducts may involve the vagina also, 
which is then single or double, the septum extending entirely or 
partially through its length. 

Such irregularities are of obstetric interest only as they com- 
plicate gestation and parturition. Labor may be retarded by the 
septum, or if the placenta is attached to it severe hemorrhage fol- 
lows, and it is frequently lacerated and even destroyed in delivery. 
Irregular presentations, retention of the placenta, and rupture of 
the uterus from defective development of its walls are common. 
The character of gestation and delivery in uterus unicornis resem- 
bles that of similar processes in tubal pregnancy, with ordinarily 
rupture of the deformed cornu, but gestation is normal in the de- 
veloped half. In uterus septus pregnancy may occur simultane- 



DEFORMITY OF THE PELVIS. 215 

ously in both halves, each having a decidua ; labor is apt to be 
tedious in single pregnancies, because only half power is expended, 
i.e., only the outer muscles of the impregnated side are active, the 
septum of course being powerless. 

Quite commonly these anomalies in development of the birth 
canal are unrecognized during life, unless at some accidental vag- 
inal examination for gynaecological or puerperal reasons, though 
if the vagina is double a similar condition of the uterus may be 
suspected. Numerous cases are on record in which patients have 
been subjected to abdominal section for symptoms of ruptured 
tubal pregnancy, and the lesion found to be in an undeveloped 
uterine cornu. 

Occlusion of the Cervix. — Labor may be obstructed by atresia 
of the cervix, by contraction either congenital or acquired, and by 
rigidity. Atresia is rarely complete, and must have been pervious 
to some degree before impregnation to allow it. The first stage is 
always retarded. Careful palpation with the finger tip will gener- 
ally detect the dimple, which indicates the position of the outlet, 
and steady pressure will open it. This failing, the cervix should 
be exposed through a vaginal speculum and incised from behind 
forward, the opening being enlarged either with the fingers, or an 
instrument resembling scissors, which is opened widely when with- 
drawn, or with a metallic dilator. Very exceptionally Diihrssen's 
multiple incisions are necessary. 

Cicatricial contraction of the cervix results from former injur- 
ies — cervicitis, trachelorrhaphies, syphilis, and cancer. The latter, 
l i discovered in the very early months of gestation, requires in- 
duced labor through radiating incisions with scissors or a blunt- 
pointed bistoury, but Csesarean section and hysterectomy are far 
preferable to any temporizing. 

Rigidity of the Cervix. — This condition is relatively normal in 
all primiparse, and especially distinct in "aged primiparae." Dila- 
tation is slow and ordinarily requires no interference, most cases 
yielding to time and temporizing, but is assisted by very hot 
douches repeated as often as every half-hour, enemata of chloral, 
hypodermics of morphine, and application of solutions of cocaine. 
Extreme cases may need forced manual dilatation, very rarely 
nicking the edge of the external os with scissors, but generally 



\ 



216 THE PRINCIPLES OF OBSTETRICS. 

careful traction with forceps, when the os has opened to the size 
of a silver dollar, is better. 

Incarceration of the Anterior Uterine Lip. — This condition 
should be relieved by carefully pushing the obstacle over the head 
if possible; if not, by forceps extraction or incisions of the lip 
radiating outward. 

Atresia of Vagina. — The canal may be absent congenital])' or 
obstructed by inflammatory cicatrices or septa, which are either 
annular or continuous throughout its entire length. The annular 
variety usually yields during labor to pressure of the descending 
part ; if not, incision is necessary, which may require suturing for 
subsequent hemorrhage. In atresia of the entire vagina, Caesarean 
section is ordinarily demanded. 

Cicatrices from old injuries, syphilis, cancer, or former ulcera- 
tion generally give way under the stretching of mechanical or hy- 
drostatic dilators. In cephalic presentations delivery is commonly 
effected by forceps, but exceptionally Caesarean section is the only 
alternative. 

Haematoma may develop, more often between the birth of 
twins, to such a size that labor is obstructed. In these exceptional 
cases the tumor must be incised, the clot turned out, and if there 
is free bleeding the cavity packed with gauze, preferably iodoform. 

Cystocele and rectocele, if large enough to affect delivery, 
should be replaced if possible, but prolapse of the vaginal walls to 
such an extent is very unusual. 

Atresia of the Vaginal Outlet. — Unruptured hymen when com- 
plicating delivery requires incision. Other forms of atresia, 
oedema of the vulva, thrombus, cancer, and simple rigidity com- 
monly yield to forceps or possibly to episiotomy. 

Solid Tumors of the Birth Canal — Solid tumors when movable 
should be pushed above the presenting part if possible, the woman 
being in the knee-chest or Trendelenburg position. Should this 
fail, they must be enucleated or removed by transfixion of the 
pedicle and ligation, followed by immediate forceps extraction or 
version, and afterward by tamponade of the cavity with gauze. 
The maternal mortality in these cases is high, from forty to fifty 
per cent ; fetal, to even sixty per cent. Sloughing, mortification 
of the uterus, and septic infection after delivery are likely. 



DEFORMITY OF THE PELVIS. 



217 



Our present knowledge upon this subject is summarized as 
follows: i. In the great majority of instances in which fibroid of 
the uterus and pregnancy coexist, the course of pregnancy and 
subsequent labor is not serious- 
ly influenced by the tumor, 
but in a small proportion of 
cases the patient's life and 
that of the child are material- 
ly threatened. 2. When preg- 
nancy is complicated by fibroid 
it is best to allow the preg- 
nancy to go to term, so long 
as the mother's health is not 
decidedly affected. 3. If it 
seems certain, either at the 
beginning of labor or shortly 
after, that the tumor will ob- 
struct birth of the child, Ce- 
sarean section followed by 
hysterectomy should be per- 
formed. 4. When the health of the mother requires interference 
in the earlier months, abdominal section should be performed and 
if possible enucleation of the tumor. 5. If then myomectomy 
is found to be too dangerous, hysterectomy should be performed.* 

Large cysts, either ovarian or elsewhere in the cavity of the 
pelvis, can usually be aspirated during labor and subsequently re- 
moved, but Cesarean section may be necessary for relief of any of 
these forms of obstruction. 




Fig. 



87.— Labor Obstructed by Uterine 
Polypus. (After Tyler Smith.) 



Doran : Abstract of paper, N. Y. Med. Jour., February 15th, 1902. 



CHAPTER III. 



III. IRREGULARITIES IN PASSENGERS. 



Occipito-posterior Positions. — The relative infrequency among 
the four vertex positions of O. D. A. and O. L. P. when com- 
pared with the others suggests the assumption that practically 
there are but two situations of the vertex. The first of these, O. 
L. A., has been considered in the chapter on Normal Labor. The 
second, O. D. P., offers no special hindrance to delivery in the 

large majority of cases, owing to 
spontaneous anterior rotation of 
the occiput. But a small number, 
in which this rotation fails, are 
liable to tax the skill and inge- 
nuity of the obstetrician to the 
utmost, because of emergencies 
which thereby threaten the life of 
both mother and child during ex- 
traction. 

Frequency. — In thirty per cent 
of all vertex presentations the oc- 
ciput engages posteriorly to the 
right, O. D. P. 

Etiology. — The causes are: I. 
Imperfect flexion of the head, for 
which irregularity two explanations 
are offered: (a) When the child's 
abdomen is in front it accommo- 
dates itself to the uterine cavity by extension of the spine and 
head; and (b) when the occiput is posterior the biparietal diam- 
eter lies in the oblique pelvic diameter, which being too narrow 
offers greater resistance to descent of the head and normal flexion 
is prevented. 2. Failure of resistance of the pelvic floor, which 

218 




FIG. 88.— Taken from a Photograph of 
a Frozen Section by Pinard and 
Varnier, showing Extension of 
Spine when the Occiput Lies Be- 
hind. (Herman.) 



IEEEGULAEITIES IX EASSEXGEES. 



219 



normally rotates the occiput forward into either anterior position. 
3. Pelvic contraction, which interferes with natural mechanism. 

Diagnosis. — External palpation indicates that the dorsum of 
the child is to the right of the median line of the abdomen, the 
head below in the brim, and the extremities above to the left. 
The focus of auscultation is to the right and posterior, and the 
shoulder, if distinguished, is behind the right lateral line. Inter- 
nally the greater fontanel is to the left of the centre of the pelvic 
cavity, the smaller well behind, the sagittal suture being in the 
left oblique diameter. If any doubt of the position exists after 
using these ordinary methods of diagnosis, it is established by pass- 





FlG. 89.— Head Presenting at Brim ; 
Occiput in Front. Biparietal diame- 
ter lying in oblique diameter of pel- 
vis. (Herman.) 



Fig. 90.— Head presenting at Brim ; 
Occiput Behind. Biparietal diameter 
lying behind oblique diameter of pel- 
vis. (Herman.) 



ing two fingers or the whole hand into the uterus and determining 
in which direction the rim of the ear points. Ordinarily if the 
heart sounds are to the right in the first stage, an occipito-posterior 
position is likely. 

Influence upon labor. — Failure of anterior rotation is danger- 
ous to the mother from tedious dilatation, probability of laceration 
of the outlet in primiparae, exhaustion, and operative delivery ; to 
the child, from distortion of the head and injury from extraction 
and its delays, fetal mortality being about fifteen per cent. 

Treatment. — There are two classes of deliveries, easy and diffi- 
cult. 

1. Easy cases. There is little interference with normal mech- 
anism, particularly rotation forward, and commonly labor is similar 



220 



THE PRINCIPLES OF OBSTETRICS. 



to that in the occipito-anterior positions. The head presents 
well flexed, readily descends to the pelvic floor, turns forward, and 
birth is thereafter normal. 

2. Difficult cases. These depend upon anomalies in the three 
factors of labor : inefficient expulsive force, irregularities in the 
passages, and failure of flexion because of disproportion between 
the child and the birth canal from any cause. Successful manage- 
ment depends largely upon recognizing the position before en- 
gagement. 

A. Treatment before engagement. Wait for full dilatation if 
possible, meantime supporting the patient by easily digested food 

and relieving the tedium of suf- 
fering by chloral or an occasional 
hypodermic of morphine. The 
membranes should be preserved 
as long as practicable, and vag- 
inal examinations repeated only 
when necessary to observe the 
progress of engagement. During 
the first stage she should general- 
ly lie upon the left side, in order 
that the force of gravity may 
rotate the child anteriorly. 

Natural correction by post- 
ure failing, when dilatation is 
two-thirds accomplished, or at any 
time immediately after rupture of 
the membranes, the author is accustomed to explain to the woman, 
if of ordinary intelligence, that her child is in an improper position 
in the womb, which can be corrected with entire safety to herself 
and with much better chances for its birth alive if she will consent 
to an examination under ether. Permission being given, anaesthe- 
tize with A. C. E., pass the right hand into the uterus, palm tow- 
ard the front of the child, and, if already engaged, lift its head out 
of the brim. Then grasp the face firmly and rotate the head (to 
the right, if originally O. D. P.; to the left, if O. L. P.), at the 
same time with the external hand lifting the under shoulder by 
successive pushes toward the median line of the abdomen. The 




PlG. 9i. — Showing Pressure Marks on 
Head After a Labor with Flat Pelvis. 
(After Fritsch.) 



IRREGULARITIES IN FASSEXGERS. 221 

shoulder must turn with the head, or the latter will not remain 
anterior. When forward rotation has been effected, which is or- 
dinarily not difficult if this method is adopted, act according to 
circumstances ; either hold the head in its new position until it be- 
gins to descend by force of contractions, or if thought best apply 
forceps to draw it into the cavity. The remainder of delivery may 
be completed either spontaneously or by forceps. Many operators 
prefer podalic version for these cases in the first stage. 

B. Head already engaged. If spontaneous rotation does not 
occur after two or three hours, three methods are advised: j. Ap- 
ply axis-traction forceps, or the ordinary form with the addition of 
Reynolds' traction rods, when impaction has occurred and there is 
evident disproportion, intermitting extraction often to permit nat- 
ural rotation, and changing to short forceps when the head is 
about to emerge, or removing it entirely. The Walcher position 
may be useful in these cases (see page 266). 2. Flex the head in 
the excavation, a more scientific method but often impossible, 
pushing up the sinciput and pulling down the occiput either with 
two fingers, or the vectis, or one blade of the forceps. 3. Rotate 
the head forward in the cavity with forceps. This method is dang- 
erous for inexperienced operators, because the tips are liable to 
wound the head of the child and injure the pelvis, and difficult 
when the head is low down unless with great moulding. It is es- 
sential that the tips of the blades should be kept strictly in the axis 
of the canal, each act of rotation be slight, and the instrument fre- 
quently unlocked to permit of natural rotation. There is little 
practical danger of overrotating the head upon the spine, and it 
will frequently turn forward of its own accord when upon the pel- 
vic floor. The head should be rarely delivered with the occiput 
posterior. 

The various methods for the delivery of occiput posterior posi- 
tions may be summarized as follows : 

First stage, before engagement or immediately after. (1) 
Spontaneous forward rotation by posture; (2) with good flexion, 
temporizing; (3) combined external and internal rotation forward; 
(4) podalic version 5(5) temporizing and 1ow t forceps ; and (6) axis- 
traction forceps at the brim. 

Second stage, head in excavation. (1) Promote flexion and 



222 THE PRINCIPLES OF OBSTETRICS. 

make traction with fingers, vectis, or blade of forceps 5(2) rotation 
forward with forceps; (3) forceps; (4) very exceptionally crani- 
otomy, symphyseotomy, and Cesarean section. 

Face Presentations. — Frequency. — Presentations of the face 
occur about once in two hundred and fifty labors. 

Etiology. —These irregularities are caused by extension of the 
head during labor, from any condition, either maternal or fetal, 
which prevents entrance of the occiput into the brim. Specifically 
the causes are deformed pelvis in any variety (transverse face 
presentations, mentum to one side, sinciput to the other, always 
suggest contraction), extreme uterine obliquity, a most frequent 
cause, pendulous abdomen, anomalies in size of the child, either 
too large or too small, twins, prolapse of the cord or an extremity, 
hydramnios, and impaction of occipito-posterior positions. 

Positions. — The chin is equivalent to the occiput and follows 
similar movements. The four classical positions are as follows: 

Right mento-anterior, mento-dextra-anterior, M. D. A. 

Right mento-posterior, mento-dextra-posterior, M. D. P. 

Left mento-anterior, mento-laeva-anterior, M. L. A. 

Left mento-posterior, mento-laeva-posterior, M. L. P. 

Practically there are but two face positions : face to left, left 
mento-iliac ; face to right, right mento-iliac. 

Mechanism. — Extension corresponds to flexion in vertex pres- 
entations, the fronto-mental diameter engaging in the left oblique 
pelvic diameter, with the chin toward the left acetabulum and the 
sinciput to the right sacro-iliac synchondrosis. 

Descent and rotation forward. The face descends, the chin 
turns forward and inward to the symphysis, and the sinciput back- 
ward to the hollow of the sacrum. 

Flexion corresponds to extension in vertex cases. The base 
of the lower jaw revolves upon the pubic rami; the chin engages 
under the symphysis, passes over the perineum, and is followed 
by the mouth, the eyes, and the forehead in the order named, birth 
occurring during flexion. 

Restitution of the head and delivery of the remainder of the 
body are similar to like movements in vertex presentations. 

Irregularities in Mechanism. — Delay in anterior rotation of the 
chin results from differences in length of the neck (one and one- 



IBBBGULABITIES IX FASSEXGEBS. 223 

half inches) and lateral depth of the pelvis (three and one-half 
inches). The face does not meet with that resistance of the pelvic 
floor necessary to produce the forward movement without which 
birth is impossible. It is also impossible in persistent posterior 
face positions, with normal-sized head and canal, because the sacral 




Fig. 92.— Face Sunk Down into the Pelvis with Chin Behind. Wedge-like blocking 
of brim of Pelvis by cranium and chest. (After R. Barnes.) A, B, C, Wedge 
formed by head and upper part of chest. (X. B. — This can happen only with a 
small child.) 



wall, being still longer (five inches) than the lateral, forward rota- 
tion is again lacking. In these cases the upper portion of the 
chest is driven into the excavation along with the back part of the 
head, both combining to form a mass too large for any pelvic diam- 
eter to admit, and further progress is arrested. 

Diagnosis.- — There is unusual prominence of the hard, round 
head on one side only of the brim, between which and the child's 
back the groove of the neck is sometimes distinct, fetal heart 
sounds being loudest on the side of the abdomen opposite the 
child's dorsum. The presenting part is high up in the vagina, 
where the finger distinguishes the eyes and projecting supra- 
orbital ridges, the nose, the mouth with its hard alveolar processes, 
and the chin. When the presenting surface is much swollen from 



i>l>4 THE PRINCIPLES OF OBSTETRICS. 

long pressure of the vaginal walls and differentiation of the part is 
obscured by a large caput succedaneum, the hard gums distinguish 
the mouth from the anus, the latter being a soft elastic ring. 

Prognosis. — Mento-anterior, and posterior cases which rotate 
anteriorly, have the same dangers as vertex presentations, but per- 
sistent posterior cases are nearly always fatal to the child, prog- 
nosis depending upon complications. Inertia uteri, disproportion 
between passenger and passage, prolapse of extremities and cord, 
all are more frequent than in normal presentations, with more or 
less disfigurement of the face. Fetal mortality is about fifteen 
per cent ; maternal mortality depends upon the management. 

Treatment. — Convert a face presentation into a vertex, the sub- 
stitution being impossible when the face is engaged in the cavity, 
in contracted pelves, with large child, and difficult if the mem- 
branes have ruptured. The simplest method is to press up the 
chin with two fingers in the vagina and exernally push down the 
occiput, continuing the manipulation until flexion is established. 
Schatz's method is as follows : Place the woman in the knee-chest 
or Trendelenburg position, make external pressure with both hands 
below and in front of the shoulders, pushing them upward and 
toward that side to which the child's back is turned. If this suc- 
ceeds, then press up the shoulders, simultaneously pushing the 
breech in the opposite direction and downward in order to bend 
the spine. Flexing the spine flexes the head, but all management 
of this kind often fails. 

Before engagement try the effect of posture in either the knee- 
chest or Trendelenburg position, preserving the membranes until 
full dilatation, and while waiting do not interfere. If the mem- 
branes are ruptured and the face is descending, leave progress to 
natural efforts. If there is no descent, there is probably dispro- 
portion (either large head or contracted pelvis), the proper treat- 
ment being to wait for full dilatation, then make podaiic version. 
When the head has been stationary in the pelvis for two hours 
and pains are good, deliver by forceps. 

Chin Posterior. — Wait for spontaneous rotation two hours after 
full dilatation, when, if there is no progress with strong pains, lift 
the head if possible out of the cavity, turn the chin forward with 
the hand, and deliver with forceps. Extraction by forceps in face 



IRREGULARITIES IX PASSENGERS. 



225 



posterior positions is very dangerous to the child, but in favorable 
cases (small child and roomy pelvis) the head may be rotated an- 
teriorly by forceps and then successfully delivered. When the 
face is impacted and the child living, symphyseotomy may be con- 
sidered ; but if dead, the elective operation is craniotomy. 

Brow Presentations. — These are a variety of face presentations, 
in which there is incomplete flexion, the head remaining through- 




FIG. 




FIG. 94. 



Figs. 93 and 94.— Showing Schatz's Method of Rectifying Face Presentations.) 

(Herman.) 



out delivery midway between flexion and extension. It is also the 
most unfavorable for both mother and child of all irregular pres- 
entations and very unusual, occurring but once in eighteen hun- 
dred cases. 

Frequency of Positions— -The brow presents in the usual four 
positions, of which brow O. L. A. and brow O. D. P. are about 
equally frequent. 

MecJianism. — The brow enters the brim with great difficulty, 
the mento-frontal diameter averaging five and one-quarter inches, 
15 



22G THE PRINCIPLES OF OBSTETRICS. 

while the longest pelvic diameter is but five inches, and only after 
extreme moulding. Under rarely favorable conditions the fore- 
head turns forward and the occiput backward into the hollow of 
the sacrum. The root of the nose is arrested at the pubic arch, 
while the occiput descends along the posterior vaginal wall until 
it emerges at the perineum. The nose and chin finally pass out 
under the arch, and the head, in anterior positions, is born ex- 
tended. Natural delivery in brow posterior positions is impossi- 
ble, the head diameters being too large for pelvic accommodation. 

Diagnosis. — The presentation is imperfectly distinguished by 
external palpation, the most that can be determined being that the 
two extremities of the head are nearly on a level. By vaginal 
examination the middle of the frontal suture appears at the uterine 
outlet; the lower jaw is on one side and the middle of the sagittal 
suture on the other. 

Treatment. — Delivery is always protracted^ and usually requires 
assistance. If the head is engaged, (i) change the brow to face by 
similar manipulation as in face presentations (pulling down the 
occiput and pressing up the face); or (2) reverse the process, 
pulling down the face and pushing up the occiput. Anaesthesia 
is necessary, either method often fails, and is impossible in pos- 
terior cases. 

Head not engaged. If the cervix is dilated make podalic ver- 
sion, the chief danger being fatal pressure upon the cord. If im- 
paction has already taken place, deliver by forceps with moderate- 
sized head ; if large, by symphyseotomy or perforation. 

Generally speaking, the elective operation for all brow pres- 
entations is podalic version. 

Breech Presentations. — Three varieties are recognized: (1) 
The thighs are flexed upon the abdomen, the knees being also 
flexed with heels resting upon the buttocks. This position is best 
for the child, because it dilates the cervix more easily than the 
vertex. (2) Thighs flexed, legs extended, feet touching the face. 
(3) Either or both feet presenting. 

Frequency. — Pelvic presentations occur about once to every 
sixty births at term. 

Etiology. — All conditions which interfere with engagement of 
the head, such as tumors of the uterus, pendulous abdomen, con- 



IRREGULARITIES IJ\ r FASSEXGERS. 



221 



tracted pelvis, placenta prsevia, hydrocephalus, and hydramnios. 
The pelvic ovoid is lowest quite often with premature or dead 
children; with twins, because one adapts itself in this position 
more easily to the other; and monstrosities. It is found that in 
oblique positions of the foetus, at commencement of labor, knee 
and foot presentations are rather more usual than those of the 
breech, and in contracted pelves the foot than breech. 




Fig. 95. — Showing what is meant by "pendulous belly." (After R. Barnes.) 
A, E, Normal axis of uterus and child ; B, P, axis of uterus and child with pendu- 
lous belly ; S, symphysis pubis ; C\ D, line indicating path of fetal head round 

pubis. 



Positions. — Position depends upon the direction of the sacrum, 
which ordinarily engages in one of the oblique diameters. The 
four classical positions are: 

Left sacro-anterior, sacro-laeva-anterior, S. L. A. 

Left sacro-posterior, sacro-lseva-posterior, S. L. P. 

Right sacro-posterior, sacro-dextra-posterior, S. D. P. 

Right sacro-anterior, sacro-dextra-anterior, S. D. A. 

Of these varieties, S. D. A. and S. L. P. are most frequent. 
Knee and foot presentations are probably caused by active move- 
ments of the child, and occur secondarily. 

Mechanism. — The first stage is long, because the breech is too 
small to dilate the cervix sufficiently for passage of the larger, 



228 



THE PRINCIPLES OF OBSTETRICS. 



firmer head, and therefore cervical lacerations are frequent in these 
presentations. The bitrochanteric diameter enters one of the 
oblique diameters, descends until the posterior hip meets the pelvic 
floor along which it moves, the breech as a whole curving forward 
by flexure of the trunk sidewise. The anterior hip turns forward 







Fig. 96.— Breech Presentations. (From an old German Atlas.) 

and the posterior backward into the hollow of the sacrum, from 
which it escapes through the outlet. As the perineum slips over 
the child's pelvis the trunk straightens, and the anterior hip passes 
under the symphysis. The shoulders engage with their transverse 
axis in an oblique diameter, the anterior being arrested by the arch 



IRREGULARITIES IN PASSENGERS. 



229 



while the posterior is being delivered. The after-coming head nor- 
mally engages in an occipito-anterior position, and, if well flexed, 
follows a similar mechanism to that of vertex presentations. 

Irregularities of Mechanism. — These depend largely upon fail- 
ure to preserve flexion of the extremities and head, owing. to in- 
creased friction of these parts against the walls of the canal. In 
dorso-posterior positions the occiput usually turns spontaneously 




Fig. 97.— Delivery of the After-Coming- 
Head with Face Anterior ; Head Ex- 
tended. (Herman.) 



FIG. 98. — Delivery of the After-Coming 
Head with Face Anterior ; Head Flexed. 
(Herman.) 



forward, but if it does not it is born by rotation about the edge 
of the perineum, the chin escaping first as in anterior positions, or, 
if arrested by the symphysis, the occiput emerging first. If the 
legs become extended, lateral flexion of the trunk may be prevented 
and further progress stopped. Extension of the arms interferes 
with descent from blocking the passage with their additional bulk, 
thus aggravating the inherent difficulties of delivery. 

Diagnosis. — Auscultation and external palpation show the head 
above, breech below, and heart sounds above the umbilicus. 



230 



THE PRINCIPLES OF OBSTETRICS. 



Vaginal examination reveals a conical protrusion of the membranes, 
the presenting part is high, while the hard round head with its dis- 
tinguishing fontanels and sutures is absent. The finger recog- 
nizes in their stead the tuberosities of the ischia, genitals, thighs, 
and one or both feet. Expulsion of meconium is not a reliable 
symptom of pelvic presentations, since it is also often present in 
those of the vertex. 

Prognosis. — The first stage is ordinarily long and the second 
often rapid, disturbance of normal mechanism of dilatation and 

hasty expulsion are productive 
of lacerations of the cervix, 
and operative delivery in prim- 
iparae is almost always accom- 
panied by rupture of the per- 
ineum. For the child there is 
liability of asphyxia from in- 
terference with its circulation 
caused by contractions of the 
uterus after birth of the trunk 
and compression of the cord 
between the after-coming head 
and pelvic walls, danger sig- 
nals being feeble irregular pul- 
sations of the cord following 
delivery of the trunk, twitch- 
ing of the legs, and spasmodic 
attempts at respiration. Ma- 
ternal mortality in spontaneous 
delivery is from one to three 
per cent, and fetal from one 
to ten per cent, but either de- 
pends upon the character of professional treatment. 

Treatment. — External cephalic version is allowable before en- 
gagement, under exceptional favorable conditions, but its advan- 
tages are counterbalanced by the risk of operation. Successful 
management of a persistent breech presentation tests the skill of 
the most experienced accoucheur, and is accomplished only by 
thorough knowledge of its various problems and their solution. 




Fig 



99.— Bringing Down One Foot. 
R. Barnes.) 



(After 



IEEEGULAEITIES iy PASSENGERS. 



231 



First stage : Preserve the membranes as long as possible, in 
order to gain their full dilating action, meantime interfering as lit- 
tle as practicable. Imperfect dilatation is likely to result in arrest 
of the head, because the external os has not been opened by pas- 
sage of the trunk sufficiently to permit exit of the head also, which 
therefore is prevented from descending by grasp about its neck of 
the two-thirds opened cervix. This condition is evidently more 
probable with footlings and premature children, in whom the head 
is always the largest extremity, and encouraged by hasty traction, 




FlG. ioo.— Bringing Down One Leg. (After R. Barnes.) 



which causes loss of cephalic flexion and extension upward of the 
arms. For these reasons, do not interfere with spontaneous dila- 
tation in breech presentations, although if the feet present it is 
proper to draw down one of them. 

Second stage : If the cervix is fully dilated but the breech does 
not descend after an hour or two, tire cause is probably a contracted 
pelvis, or a large child, or feeble pains, or a combination of them. 
With the first two, draw down one leg to lessen by so much the 
bulk of the breech, and possibly steady traction will complete de- 
livery. If pains are feeble, with or without irregularity in the size 
of the pelvis or the child, stimulate greater uterine power by trac- 



232 



THE PRINCIPLES OF OBSTETRICS. 



tion upon one leg and external pressure upon the fundus. In 
prolapse of the cord also bring clown one leg, in order to be able 

to hasten delivery if the child's 
life is threatened. 

Method of Bringing Down 
One Leg. — Anaesthetize the 
woman and put her in the lith- 
otomy position, skilled assist- 
ance being almost an essential 
in these cases. Pass into the 
uterus that hand whose palm 
faces naturally the child's ab- 
domen, between pains, having 
the assistant make counter- 
pressure at the same time 
upon the fundus. Grasp the 
nearest foot ; if the leg is ex- 
tended upon the trunk, press 
the knee outward and back- 
ward which flexes it, draw 
across the child's abdomen 
during pains, and deliver by 
steady, careful traction. If the 
position was originally dorsum posterior, traction should be in a 
spiral direction in order to rotate the back 
forward. 

Delay from Feeble Pains. — After discharge 
of liquor amnii, progressive retraction of the 
uterus upon the child and cord obstructs their 
circulation, the danger being recognized by 
auscultation of the fetal heart. Under fatal 
compression its action grows slower, becomes 
intermittent, and finally ceases. Delivery may 
require to be hastened for this reason and to 
relieve the mother from the exhaustion re- 
sulting from incessant suffering. Make trac- 
tion by the index finger (right in left sacro- FlG - io2.-cord snared 

. . . , r • - i . N bv Catheter with Sty- 

antenor positions, left in right sacro-antenor) let (Herman ) 




Fig. 



-Digital Traction upon Posterior 
Hip. (After R. Barnes.) 




IRREGULARITIES IN PASSENGERS. 



233 



upon the anterior groin, changing to the posterior as soon as it 
descends low enough to be reached, and pulling with pains. In 
ordinary cases this method is sufficient. 

Delay from Disproportion (large child, small pelvis). — Bring 
down one leg and make traction upon the breech, by either two fin- 
gers, or a fillet of cloth or rubber tubing, or blunt hook. The fin- 
gers are always safer and 
more serviceable than any 
other instrument, and the 
method has already been 
described (page 231). 

Fillet — Select a strip 
of any strong cloth, one 
yard long, previously ster- 
ilized in bichloride, and tie 
a knot in one end, or use 
a piece of half-inch rubber 
tubing through which has 
been passed a strong cord. 
When the breech is still 
high in the cavity, it is 
often very difficult to pass 
the fillet about the groin 
with the fingers. The fol- 
lowing method is suggest- 
ed : Sterilize a large Eng- 
lish male catheter, draw 
the stylet below the fenes- 
tra, into which pass a loop of sufficiently strong cord and thread 
it with the stylet. This fastens the cord to the catheter, which is 
then curved like a blunt hook and passed together with the cord 
around the child's groin. The stylet is next removed, freeing the 
cord, which is then caught by the finger and withdrawn, with the 
catheter, from the vagina. An end of the cord is fastened to 
one extremity of the fillet, which is then drawn into the vagina, 
around the groin, and out of the vulva. This method is suc- 
cessful enough to deserve careful trial. 

The rubber tube may be substituted for the cloth, because less 




Fig. 



Bringing Down the Arms. 
Farabeuf.) 



(After 



234 



THE PRINCIPLES OF OBSTETRICS. 



likely to injure the soft flesh of the child ; but the hook is, like all 
similar appliances, very dangerous both to mother and foetus, and 

should be reserved for dead 
children. 

In dor so-posterior posi- 
tions the fillet may be placed 
so as to surround the child's 
pelvis, the extremities hang- 
ing between its thighs ; but, 
however arranged, care 
should be taken to keep it in 
the flexure of the groin dur- 
ing traction to avoid fractur- 
ing the thigh. 

Forceps in Breech Extrac- 
tion. — In difficult breech de- 
liveries many operators pre- 
fer forceps to any form of 
extractor, though others do 
not hesitate to condemn it. 
The blades are applied over 
each trochanter, or one over 
the sacrum and ilium and the 
other over the opposite thigh, 
traction being always mod- 
erate and reinforced by press- 
ure upon the fundus (expressio uteri). The practical objection 
to this method of delivery is that the instrument is likely to slip 
upon the greasy surface of the child, and make dangerous com- 
pression of its viscera and tissues. In high arrest of the breech, 
axis-traction forceps are undoubtedly preferable to the ordinary 
model. 

Delivery of Arms. — Anticipate operation by all needful prepar- 
ations of instruments, napkins, hot douches for hemorrhage, etc., 
since every moment's detention of the head in the cavity after the 
arms are extracted reduces the chances of getting a living child. 
As soon as the body is born as far as the umbilicus, draw down a 
loop of the cord, placing it in the position of least pressure and 




FlG. 104. — Dorsal Displacements of 
(After R. Barnes.) 



IRREGULARITIES IN PASSEXGERS. 



235 



examining it often for evidences of weakening circulation. If the 
arms are flexed upon the chest, deliver by traction upon the flex- 
ure of the elbow, avoiding pressure upon the humerus or forearm, 
which are likely to be fractured thereby. If extended, draw down 
the trunk as far as possible by traction upon the breech, protecting 
it from the air and injury by wrapping about it a sterilized napkin, 
which also provides the hand with a firmer grasp upon the slip- 
pery surface. Deliver the posterior arm first if possible, passing 
the hand over the child's shoulder down the arm to the elbow, 
and pushing the latter across the face downward. To deliver the 
second arm, rotate the 
body so that the unde- 
livered arm shall lie in the 
hollow of the sacrum, push 
the trunk and head back 
into the uterine cavity to 
free them from the grasp 
of the brim, afterward ex- 
tracting the arm in a man- 
ner similar to that of the 
other. 

Nuchal Arm. — If either 
arm is caught behind the 
head in the nape of the 
neck ("nuchal arm"), 
rotate the body in the opposite direction 
unlock it, and deliver as directed. This bein 
impracticable, the alternative is to extract th 
head forcibly, though the arm will probably be 
fractured. 

Instead of confusing the reader with the 
minutiae of various methods of delivery in diffi- 
cult pelvic presentations, two only need to be 
familiarized. 

Derventer's Method in Low Arrest of the 
Head and Arms. — Drop the body of the child downward as soon 
as the lower border of the scapulae appears, grasp the feet with 
one hand, and press the fingers of the other upon the top of the 




Fig. i 05. — Derventer 
Method of Delivery of 
After-Coming Head. 



236 



THE PRINCIPLES OF OBSTETRICS. 



shoulders. Draw the child perpendicularly down, the mother 
being in the lithotomy position, when the occiput will present 
under the symphysis, the sinciput and face following with the 
arms. 

Prague Method in High Arrest. — Skilled assistance is necessary 
for anaesthesia and f undal pressure. Seize the feet with one hand, 




FlG. 106.— The So-called "Prague" Method of Delivering the After-Coming Head. 



draw the body downward as far as the perineum allows, hook the 
other hand over the shoulders, and make traction with both to- 
gether. As the head descends the body is quickly turned upon 
the mother's abdomen, the hand upon the neck assisting flexion 
by pressing back the occiput, the special disadvantage of this 
method being the liability to make injurious traction upon the 
neck. When the Prague method is impracticable, forceps, partic- 
ularly the axis-traction form, is by many thought the best alter- 
native. 

Delivery of the After-Coming Head. — All things considered, 



IRREGULARITIES IX PASSEXGERS. 



237 



the best method is by forceps. Have an assistant hold the child's 
body high up on the mother's abdomen, apply forceps under the 
trunk to the head, extraction being usually easy without danger to 
the mother, and quickest for the child. Haste at this time is im- 




FlG. 



[07.— Demonstrating upon the Phantom Method of Delivery of the After-Coming 
Head with Forceps. 



perative, because unless the head follows the body within five 
minutes the child becomes asphyxiated. 

Axioms in Breech Deliveries. — 1. During the first stage, has- 
ten slowly. 2. If occiput is originally posterior, rotate it forward 
during traction. 3. Keep the child in a compact mass (preserve 
flexion), by suprafundal pressure during extraction. 4. Cover 
with hot towels that portion of the child already delivered, while 
extracting the head. Contact with the air stimulates premature 
breathing. 5. If the face is not born within five minutes after 
delivery of the body, the child dies from asphyxiation. 



CHAPTER IV. 

IRREGULARITIES IN PASSENGERS, CON- 
TINUED. 

Transverse Presentations. — These include all presentations ex- 
cept those of the head and breech. The long axis of the child lies 
across that of the uterus, the majority of cases being oblique rather 
than transverse, and when labor begins almost always changing to 
the shoulder. 

Frequency. — The irregularity occurs about once in two hundred 
and fifty labors. 

Etiology. — The causes are practically similar to those for pel- 
vic presentations : I . Dead or premature children, with whom this 
presentation occurs once in every eight labors, but only once in 
every two hundred and fifty living at term. The faulty presenta- 
tion is ascribed to a change in the centre of specific gravity induced 
by decomposition or lack of development. 2. Increased flexibility 
of dead children. 3. Non-engagement of the head from uterine 
obliquity, either lateral or forward. 4. Hydramnios. 5. Obstruc- 
tion of the pelvis, caused by deformity, tumors, etc. 6. Placenta 
praevia and twin pregnancies. 

Position. — This is determined by the direction toward which 
the scapula looks, " right " and " left " referring in all of its posi- 
tions to the corresponding side of the mother rather than to that 
of the child, i.e., scapula to the left and front, the position is left 
scapula-anterior; to the right and front, right scapula-anterior. 
The four classical positions are : 

Right scapula -posterior, scapula-dextra-posterior, Sc. D. P. 

Left scapula-anterior, scapula-laeva-anterior, Sc. L. A. 

Left scapula-posterior, scapula-laeva-posterior, Sc. L. P. 

Right scapula-anterior, scapula-dextra-anterior, Sc. D. A. 

In practice there are ordinarily but two positions : Right lateral 
presentations, including right arm, shoulder, elbow, hand, etc.; 
left lateral presentations, those of the left arm, shoulder, etc. 

238 



IRREGULARITIES IN PASSENGERS. 



239 



Diagnosis. — Abdominal palpation shows that the child is trans- 
verse in the uterus, the head being in one or the other side of the 




Fig. 108.— Transverse Presentations. (From an old German atlas.) 

pelvis, and the breech opposing it. Per vaginam, the presenting 
part is high up, there is conical projection of the membranes if 



240 



THE PRINCIPLES OF OBSTETRICS. 



unruptured, and absence of distinctive head symptoms or breech. 
The finger recognizes the axilla, clavicle, scapula, acromion proc- 
ess, humerus, and ribs, the axilla and elbow turning toward the 
foot. A prolapsed arm or hand is differentiated by shaking hands 
with the child (page 143), the right hand of the operator naturally 
taking its right hand, and vice versa. 

Mechanism. — There is no proper mechanism for transverse 
presentations, which in a majority of cases spontaneously change 




FlG. 109. — Spontaneous Evolution in 
Progress. Arm outside vulva ; side of 
neck behind pubis, side of chest press- 
ing on perineum. (Herman.) 



FlG. no.— Further Stage of Spontaneous 
Evolution. Side of neck still fixed be- 
hind pubis ; chest and pelvis delivered, 
legs about to follow. (Herman.) 



to longitudinal at the commencement of labor, but if persistent 
the shoulder or arm engages. In neglected cases there is ordi- 
narily impaction of the shoulder, extreme tonic contraction of the 
uterus with great distention of the lower segment, and ascent of 
the contraction ring. Natural delivery is exceptionally by one of 
two methods : ( 1 ) Spontaneous version, in which there is sponta- 
neous change of the shoulder to breech and birth in that position 
(version always taking place in the uterus, never in the vagina), 
said to be more frequent in multiparae than in primiparae, at the 
bsginning of labor rather than in the second stage, and with living 



IRREGULARITIES IN PASSENGERS. 



241 



rather than dead children; and (2) spontaneous evolution, in which 

the breech slides past the shoulder, and the trunk, folded together, 

is born by expulsion of the 

breech. This form of delivery 

is possible only by powerful 

contractions of the uterus upon 

a premature dead child. 

Prognosis. — In uncorrected 
transverse presentations, ma- 
ternal mortality is from one 
to ten per cent, dangers being 




FlG. 112 —Spontaneous Expul- 
sion. Child doubled up; legs 
and head expelled together. 
(Herman.) 

16 



FlG. hi.— Termination of Spontane- 
ous Evolution. Delivery of trunk 
and lower extremities complete; 
head and posterior arm about to 
follow. (Herman.) 

due to rupture of the uterus, 

septic infection, and effects of 

pressure upon the canal; fetal 

mortality is about fifty per cent, from 

compression in spontaneous delivery 

and prolapse of the cord. 

Treatment. — Before labor correct 
manually, either in the knee-chest or 
Trendelenburg position, by external 
version, and fix the child in the lon- 
gitudinal position by suitable bandag- 
ing of the mother's abdomen. After 
labor has begun, lose no time in wait- 



242 



THE PRINCIPLES OF OBSTETRICS. 



ing for natural action, but immediately perform version, ordinarily 
by podalic method, very exceptionally by cephalic. If the child is 
dead and the shoulder impacted, decapitation should precede de- 
livery. 

Compound Presentations. — When two or more portions of the 
child enter the pelvis together during labor, such as the head and 
hand, head, hand and foot, hand and foot, or "nuchal arm," the 
irregularity is called a compound presentation. 

Frequency. — The anomaly occurs once in about two hundred 
and fifty labors. 

Etiology. — The cause is a failure of the engaging part, either 
head or breech, to fill the brim, from pelvic deformity (always 




Fig. 113. — Prolapse of Foot with Hand and Cord. (Herman.) 



suggested by extension of the arm alongside the head), displace- 
ments and irregularities in shape of the uterus, hydramnios, very 
large head or malpositions of the child, and multiple pregnancies. 

Diagnosis. — The intruding part is detected by vaginal exami- 
nation at the beginning of labor, or later by unexplained delay in 
progress, distinct parts being recognized by rules already given. 

Treatment. — Generally: When the condition is found before 



IRREGULARITIES IN PASSEXGERS. 



243 



rupture of the membranes, attempt replacement of the prolapsed 
member by the effect of gravity, elevating the woman's hips 
by the knee-chest or Trendelenburg position, or by placing her 




FIG. 114.— Twin Gestation. (From an old German atlas.) 



upon the side opposite the prolapse. After rupture replace if 
possible; if not, perform podalic version or craniotomy if the child 
is dead. 

With special varieties : If the head and extremities, extract the 
head with forceps, disregarding the displacement ; hand and foot, 
make podalic version; the "nuchal arm" should be managed 
according to directions given in the section on breech presenta- 
tions. 



244 THE PRINCIPLES OF OBSTETRICS. 



IRREGULARITIES IN FETAL DEVELOPMENT. 

Multiple Births. — Labor with twins is usually undisturbed, but 
representations and emergencies at this time are more frequent 
than in single births. The former are shown in the table of 
Spiegelberg (" American Text-book of Obstetrics " ) : 

Both heads presenting 49.00 per cent. 

Head and breech 31.70 

Both pelvic presentations 8.60 

Head and tran verse presentations 6.18 " 

Breech and transverse presentations 4. 14 

Both breech 0.35 " 

Varieties of Irregular Positions. — Three classes of irregular 
positions are recognized: (1) Both heads present together, that of 
the second being caught in the neck of the first ; (2) the first de- 
scends by the breech, its chin interlocks with that of the second 
and drags it into the pelvis; (3) one presents transversely, upon 
which the second sits astride. 

Influence upon Labor. — The second child is usually born within 
an hour of the first, a longer delay indicating insufficient contrac- 
tions or some hindrance to the progress of the after-coming child. 
Uterine inertia, particularly during the second stage, is a frequent 
result of the extreme distention, post-partum hemorrhage being 
more likely than in single births, and early rupture of membranes 
as a consequence of the irregular presentations. Increased intra- 
abdominal pressure due to abnormal size of the uterus is accepted 
as one of the causes of puerperal kidney, eclampsia (many times 
more common with twins than unioval gestations) and albuminuria 
are the rule — complications that predispose to septic infection. 
Irregularities are found in the amount of liquor amnii contained in 
the separate sacs, hydramnios in one and oligohydramnios in the 
other. 

Dystocia is likely from malposition of the foetuses, an extra- 
uterine foetus having been known to obstruct the birth of an intra- 
uterine one. Owing to feebleness of the children from lack of 
development and prematurity, which latter is to be expected, and 
to complications in their delivery, fetal mortality is large. 



IRREGULARITIES IN PASSENGERS. 



245 



Diagnosis. — In twin pregnancies the uterus at term is unusu- 
ally large, wide, and tense. By external palpation an extraordinary 
number of fetal parts are found, two cephalic and pelvic poles, 
and ballottement is impossible. Two fetal heart sounds are heard 
by auscultation, of equal or different rate and in opposing loca- 
tions. Though the position of a single twin might be made out 
by vaginal examination, diagnosis of twin gestation would not be 
expected by this method. 

Prognosis. — These forms of gestation are distinctly patholog- 
ical, owing to the many complications. Ordinarily labor is easy, 




Fig. 



-Contour of Abdomen with Twins— Both presenting with the Head: 



but post-partum hemorrhage is frequent and artificial assistance or 
intra-uterine manipulation is required in about twenty-five per cent 
of cases. Delivery with interlocked twins is often impossible, the 
mother dying either from septic infection, or ruptured uterus, or 
other grave emergency. Fetal mortality is more than twice as 
great as in single births from weakness and difficulties in extrac- 
tion, and with malpresentations it is given as high as forty per 
cent. 

Treatment. — The usual course of twin labor is as follows : That 



240 



THE PRINCIPLES OF OBSTETRICS. 



child which presents first dilates the cervix the same as in single 
births, and subsequent labor is normal. The cervix then partially 
contracts, after varying intervals pains recommence, the second 
child following rapidly because the canal has been already dilated 
by the passage of the other. The placentae conform to the nor- 
mal mechanism of the third stage, that of the first child not com- 




FlG. 116.— Single Placenta with Twins. Children males. Notice nodes on funis. 



monly separating until after the birth of the second, a fact that 
explains the lack of hemorrhage during delivery. 

The general management of twin labor is similar to that of sin- 
gle. After the birth of the first child its cord should be immedi- 
ately ligated otherwise the second might die from hemorrhage due 
to anastomosis of the placental circulation. From the liability of 



IRREGULARITIES IX FASSEXGERS. 



247 



uterine inertia, full doses of ergot should be administered as soon 
as the sac of the second child is ruptured, if it has no abnormality. 

Irregular Presentations. — When both heads engage simultane- 
ously, retard one and hasten delivery of the other with forceps, or 
deliver both heads with forceps and each trunk separately after- 
ward. If the heads are in- 
terlocked, a condition recog- 
nized only by careful intra- 
uterine examination, push 
back that of the first child 
and immediately extract the 
breech of the other, or pos- 
sibly the head-first child 
may be dragged out by that 
of the other. If both of 
these methods fail, decapi- 
tate that child presenting 
by the breech and deliver 
the other with forceps, the 
knee-chest or Trendelen- 
burg position being of great 
assistance in all these ma- 
nipulations. 

Extreme Development 
of the Foetus. — The condi- 
tion is of course relative 
only, since a child of normal 
size for one mother might 
be overdeveloped for an- 
other ; but, generally speak- 
ing, when the fetal weight 
is more than twelve pounds 

it may properly be considered abnormal. Though birth of living 
children weighing more than twenty pounds has been recorded, 
such instances are obstetrical curiosities. 

Etiology. — Extreme size of the child is attributed to heredity, 
unusual stature, or advanced age in either one or both parents, and 
to prolongation of gestation. The last is accepted as the most 




Fig 



- Showing Interlocking of Twins. First 
child partly delivered with pelvic end in ad- 
vance, second with head. (After R. Barnes.) 
A, B, Plane of brim ; E, C. £>, wedge formed 
by head of first child and neck of second. 



248 



THE PRINCIPLES OF OBSTETRICS. 



obvious cause, many authorities advising induction of labor when 
it is certain that pregnancy has continued two weeks beyond nor- 
mal limits. Ordinarily children of the same sex are successively 
larger, a fact to be remembered in considering the probability of 
delivery in contracted pelves, since it has been noticed that in 
such irregularities the first two or three children are born without 




Fig. 118.— Hydrocephalus. 



especial difficulty ; but those born later often require, from greater 
development, the most complicated artificial delivery. 

Diagnosis. — The condition is rarely detected before labor. If 
suspected, the results of external palpation and failure to push 
the presenting part into the pelvis might strengthen the hypothe- 
sis. Delay in engagement and extreme difficulty in delivery under 
presumably normal pelvic shape warrants manual intra-uterine ex- 
amination, which should solve the question. 

Prognosis. — With the ordinary sized pelvis an overgrown foetus 



IBBJEGULABITIES IX PAS8EXGERS. 



249 



often requires the severest operative delivery, during which it gen- 
erally dies, danger to the mother being from pressure symptoms, 
shock from operation, and septic infection. 

Treatment. — Delivery should be upon general principles, by 
either forceps or version, or, these failing, embryotomy. Even if 
the head is successfully extracted, the shoulders may be too large 
for passage, but as at this time the child is usually dead, embryot- 
omy should unhesitatingly be performed. When it is recognized 
ante partum that the foetus is 
enormous and after tentative 
use of forceps it cannot be 
extracted without success, 
symphyseotomy or Caesarean 
section might be properly con- 
sidered. 

Hydrocephalus. — The dis- 
ease is characterized by a 
serous effusion into the crani- 
um, causing its enlargement. 
It is somewhat frequent, hav- 
ing been found in successive 
pregnancies in the same wom- 
an, but the etiology is un- 
certain, though ascribed to 



Two 




Fig 



reco°-- 



. 119.— Hydrocephalus Head Presenting 
for Deliver}-. (Schaeffer's "Atlas.") 



syphilis and alcoholism 
forms are clinically 
nizeel: the very large hydro- 
cephalic head, exceeding the adult skull ; and that in which the 
size is but little above normal. 

Diagnosis. — The anomaly is not ordinarily detected until labor 
is in progress, an error which a more careful examination would 
probably have prevented. Before labor its characteristic symp- 
toms are found upon combined examination to be : uterine tumor 
unexpectedly large, head immense, with failure of engagement, 
unnatural mobility and flexibility of cranial bones, sutures widely 
separated, fontanels (especially the posterior) broad, prominent 
sinciput and supra-orbital ridges, and face small. Exceptionally 
cranial effusion is so slight that nearly all these signs are inap- 



250 THE PRINCIPLES OF OBSTETRICS. 

preciable upon ante-partum examination, and yet delivery may be 
impossible from lack of head moulding. 

Prognosis. — The child is always feeble and dies soon after birth, 
its mortality, depending simply upon delivery, being about eighty 
per cent. Maternal prognosis rests upon intelligent management, 
but eighteen per cent of neglected cases are fatal from exhaustion, 
hemorrhage, pressure symptoms, rupture of the uterus, and septic 
infection. 

Treatment. — When the head is small, birth may be spontaneous 
or without great difficulty. If large, the head should be dimin- 
ished by evacuation of the fluid, preferably by aspiration, a method 
not necessarily fatal to the child, though, owing to its decreased 
mental and physical vitality, such a result should be disregarded 
for the interests of the mother. A pair of ordinary long-handled 
surgical scissors should be thrust through a suture or fontanel into 
the cranial cavity and withdrawn widely open, when the fluid will 
be discharged either spontaneously, or may be washed out with a 
fountain syringe. The head then collapses, and can be extracted 
with any strong forceps, with the more scientific cranioclast, or 
cephalotribe. The ordinary obstetric forceps should not be used 
as an extractor, owing to its liability to slip and wound the canal. 
Podalic version is also not suitable, because of the liability of rup- 
turing the uterus during its performance. In breech presentations 
the after-coming hydrocephalic head offers no special difficulty to 
extraction, because under the force of delivery the fluid is driven 
from the cranial cavity into the scalp and adjacent parts. 

Puncture of the head may be made at any convenient point, 
through the occiput, behind the ear, or through the roof of the 
mouth. In breech cases Van Hueval's method is to puncture the 
spinal cord with a trocar and pass through this opening a metal 
catheter into the cranial cavity, withdrawing the fluid by gravity 
or aspiration. 

Premature Ossification of the Head. Wormian Bones. — These 
rare causes of dystocia are not usually detected until after birth. 
Diagnosis is made from the stony hardness and incompressibility 
of the skull, united sutures, and closed fontanels. Treatment 
must be on general principles by forceps, craniotomy, or capital 
operation. 



IRREGULARITIES IN PASSENGERS. 251 

FETAL MALFORMATIONS, MONSTROSITIES, AND 
TUMORS. 

In all these anomalies delivery occasionally takes place in some 
unexplained manner. The entire subject of teratology is without 
the scope of this book, but in a word labor is generally spontaneous 
and premature, by accommodation of the foetus to the birth canal. 
Podalic version is the elective operation, and embryotomy in diffi- 
cult cases. 

The two most frequent fetal monstrosities resulting from in- 
complete development of the skull are anencephalus and encepha- 
locele. 

Anencephalus. — The occiput and parietals are absent, leaving 
the base without a bony covering. The brain is deficient or rudi- 
mentary, an irregularity often associated with congenital hydro- 
cephalus and hydramnios, and there is extreme width of the 
shoulders. Diagnosis is made, per vaginam, by feeling the inte- 
rior of the skull and pulpy membranous contents. The child is 
still-born or dies soon after delivery. 

Treatment. — Labor is generally spontaneous; if it is not, 
embryotomy should be performed. 

Encephalocele. — A fluid tumor presents outside the cranium 
through a defect in union of adjacent bones, varying in size from 
an egg to that of the adult head and connected to the cranial con- 
tents by a pedicle. The tumor is attached either to the sinciput 
or to the occiput, and may or may not obstruct labor, according 
to the elasticity of the skull. When its size obstructs labor the 
sac should be aspirated or punctured with a trocar. 

EncepJialocele, with Operation {Maine General Hospital). 

Male, ten months old at operation, first child, cephalic presen- 
tation, natural delivery after twelve hours' hard labor, the tumor 
then being about the size of the fist. It has always been artifi- 
cially fed, and while small for its age is fairly nourished, all func- 
tions being normal, though there is moderate constipation. 

Status Preesens. — In front of the ears the skull is normal, but 
deficient at the junction of the occiput and parietals. Attached to 
the region of the posterior fontanel is a tense, non-fluctuating, 



252 THE PRINCIPLES OF OBSTETRICS. 

translucent tumor, probably sacculated, as indicated by the ap- 
pearance of the upper portion, with a large ulcer to the left of the 
median line. It had been aspirated at two points near the base, 
marks of the trocar being still present. Circumference of head 
fourteen inches; longitudinal circumference of tumor twenty-two 
inches, transverse eighteen inches, diameter nine by six inches. 
The child had a semi-idiotic look and nystagmus, though the nurse 
thought it appreciated light from darkness, and moving the tumor 
in any direction was followed by loud crying. 

Removal was requested, though it was explained to the family 




FIG. 120. — Encephalocele. 

that the result would be probably fatal. After aspirating a clear 
limpid fluid, the sac was freely opened and found lined with a 
fibrous capsule, probably meningeal. At the centre was a hema- 
toma, the size of a hen's egg, which projected from the cranial 
cavity through the enlarged fontanel, and at the base was a mass 
of cerebral substance. As soon as the latter was clamped, the child 
began to fail, the vessels of the face becoming turgid, but fading 
out when the clamp was relaxed. The radial pulse was good at the 
beginning of the operation, but became imperceptible as soon as 
the brain matter was handled. The intercapsular vessels were 



IBBEGULABITIES IN PASSENGERS. 253 

ligated, the redundant sac was removed, and its edges were united, 
but the child was then moribund and died six or eight hours 
afterward. 

Tumors. — Cystic tumors (ascites, hydrothorax, and other 
pathological effusions) obstruct labor exceptionally. Diagnosis is 
ordinarily not made before delivery, unless by intra-uterine ex- 
amination for difficulty in extraction. Treatment is aspiration of 
the tumor or puncture with a trocar, and extraction of the child 
by forceps, podalic version, or embryotomy. 

Solid tumors may offer difficulties similar to those offered by 
cystic tumors, and are removed, if necessary, by morcellement, the 
succeeding delivery being conducted on general principles. 

IRREGULARITIES IN FETAL APPENDAGES. 

Membranes. — When the membranes are unusually delicate 
they may rupture either some days before labor or at the begin- 
ning of the first stage. If they rupture before term, the liquor 
amnii is discharged in small quantities, particularly if the tear is 
high up. At the moment of rupture pains may be, and are ordi- 
narily, absent ; but they begin within a short time. At term, 
premature rupture prolongs and interferes with normal dilatation, 
the cervix being exposed to laceration, particularly in vertex pres- 
entations ; and under such circumstances labor is called a " dry 
birth." The first stage is always retarded, and artificial delivery 
is more often required than in natural dilatation. 

When, on the contrary, the membranes are unusually tough, 
rupture is delayed until birth of the head, or even of the entire 
body. In these cases, the face being enclosed within the sac, 
respiration of the child is prevented, and the envelope must be torn 
open immediately. The membranes are called by the laity " the 
caul " or " the veil " ; and in olden times birth with the membranes 
unbroken was thought a favorable omen for the child, the sac being 
wrapped in a small bag and suspended about its neck like an 
amulet. 

Oligohydramnios has the same clinical features as labor with 
premature rupture of the amniotic sac, and hydramnios is often 
followed by uterine inertia from the associated overdistention. 



254 THE PRIXCWJ.ES OF OBSTETRICS. 

Umbilical Cord. Irregularities in Length. — When it is too 
short, descent of the child may be prevented, or premature de- 
tachment of the placenta may occur. Diagnosis of the anomaly 
is always obscure, but it may be suspected if there are unaccount • 
able delay in progress, sharp pain at the fundus with each con- 
traction, and retraction of the head following each descent. For- 
ceps in head presentations ma)' be necessary. 

If progress is arrested by coiling of the cord about the neck 
or an extremity, draw down a loop if possible, cut it between two 
haemostats or ligatures, and deliver immediately. 

When the cord is too long, two emergencies are likely to en- 
sue : prolapse, and during the motions of the child the cord may 
become coiled once or more times around any part of it, being 
found around the neck once in every four labors. A similar con- 
dition to that caused by naturally short cords is then produced ; 
and if so, it requires the same management. 

Prolapse of the Cord. — This irregularity occurs when the funis 
presents alone or accompanies another presenting part, its fre- 
quency varying with different observers. 

Etiology. — The cause is in general anything which prevents 
the part engaged from filling the brim, particularly deformed pel- 
vis, pendulous abdomen, irregular and compound presentations, 
twins, hydramnios and small child, sudden discharge of liquor 
amnii with which the cord escapes, especially if quite long, and 
premature rupture of the membranes from accidents during travel. 

Diagnosis. — A prolapsed cord has been mistaken for a loop of 
intestine ; but with the latter there is hemorrhage, the mesentery 
should be felt, and pulsation is absent. Inspection should decide 
the question. 

Prognosis. — Fetal mortality results from asphyxia in about 
fifty per cent of cases, death being most frequent in primiparae 
and in vertex presentations. The maternal danger is not directly 
increased, but may be indirectly from any operation necessary for 
delivery. If pulsations are absent from the cord for fifteen min- 
utes the child may be considered to be dead. 

Treatment. — -When prolapse is found before rupture of the 
membranes, the patient should be anaesthetized, placed in the 
knee-chest or Trendelenburg position (the latter being extempo- 



IRREGULARITIES IN PASSENGERS. 



255 



rized by elevating her hips upon the back of a chair placed accord- 
ing to the illustration), and the cord returned manually into the 




Knee-Chest Position. 



uterus. Here it should be caught over an extremity and forceps 
immediately applied to draw the head into and plug the brim. If 




Fig. 122.— Extemporized Trendelenburg Position. 

manipulation fails, podalic version should be made at once. With 
breech presentations it should be replaced if practicable, and a 



256 THE PRINCIPLES OF OBSTETRICS. 

foot be drawn down until the breech engages firmly. If the 
breech is already impacted, act as directed for breech deliveries, 
placing the cord in the position of least resistance — e.g., if the ver- 
tex is O. L. A., opposite the left sacro-iliac synchondrosis. Re- 
placement by catheter or other appliance is disappointing, and 
manual reposition preferable. 

Rupture of the Cord. — The normal funis will part under a strain 
varying from five to fifteen pounds, and therefore it may break 
during precipitate birth of a child of ordinary weight. Rupture is 
usually at the umbilicus, occasionally in continuity, and generally 
there is no bleeding. 

Treatment. — The cord quickly resents handling by arrest of 
its circulation, therefore treatment should anticipate rupture. 
Precipitate labor should be delayed, and strong traction upon a 
coiled cord is improper, needful manipulation being always of the 
gentlest character. If separation is at the umbilicus, the funicu- 
lar vessels should be successively ligated, or harelip pins inserted 
under the navel and a figure-of-eight ligature applied. 



PART VII. 
OBSTETRIC OPERATIONS 



CHAPTER I. 
INDUCTION OF LABOR. 

Labor may be induced artificially at any period of gestation 
before viability, that is, before the seventh calendar month. 

INDICATIONS. 

When it is decided, after consultation- that the mother's life is 
distinctly imperilled by the continuance of gestation, the child's 
existence may be terminated as the less valuable of the two. 
Although most of the indications for induction of abortion or 
miscarriage have been given previously in connection with the 
pathology of pregnancy, the}' are herewith summarized for com- 
pleteness of the present topic. 

After failure of therapeutic measures, the uterus may be pre- 
maturely emptied for the following maternal causes: acute 
hydramnios or cystic degeneration of the chorion, hyperemesis 
gravidarum, placenta praevia and premature detachment when 
normally situated, irreducible uterine displacements, progressive 
albuminuria and chronic nephritis, pernicious anaemia and leuco- 
cythaemia, and particular nervous diseases like insanity, epilepsy, 
and chorea. Fetal causes are its assured death or extreme size. 
Mechanical causes are ordinarily deformity and tumors of the pel- 
vis, fibroids of the uterus, and carcinoma. 

METHODS. 

Therapeutic. — Induction of labor by drugs, even if possible, is 
entirely impracticable for the physician, and therefore dismissed 
from further consideration. 

Surgical. Krause Method. — This is safest for the general 
practitioner unused to gynaecological operations. Immerse a No. 
io English bougie or catheter in cold bichloride solution, i to 



59 



2G0 THE PRINCIPLES OF OBSTETRICS. 

1,000, for one-half an hour. Place the patient in the lithotomy posi- 
tion, sterilize the external genitals and vagina, and pass two fin- 
gers up to the cervix. Upon these as a guide insert the bougie 
or catheter to its full length into the uterus, without especial care 
as to what part of the cavity it enters. Be particular not to punc- 
ture the membranes or placenta ; in the latter case, as indicated 
by slight bleeding, withdraw the tip a little and reinsert in a dif- 
ferent situation, a second bougie being introduced when it can be 
passed without difficulty. Tying the bougie or retaining it by 
tampon is unnecessary, and if labor does not result in twenty- 
four hours this method may be considered to have failed. Under 
strict asepsis and care in passing the bougie the operation is safe, 
but it is uncertain in results and unsuitable when it is required for 
immediate delivery. 

Separation of Membranes. — Krause's method may or may not 
be preceded by detachment of the membranes from about the in- 
ternal os with the aseptic finger or sound, but being unreliable of 
itself and having the additional disadvantage that by it the dilating 
power of the membranes is lost, this method is used only as a pre- 
liminary to manual dilatation. 

Tamponade. — Application is as follows: Place the patient in 
the Sims position. Pack the vagina through a Sims speculum with 
long strips of gauze, as fully as the canal permits, and retain in 
place by a T-bandage. Remove every twelve hours, preceding 
each renewal by irrigation with normal salt solution, repeating 
the process until labor commences. The method acts slowly, and 
is especially useful for hemorrhage. 

Manual Dilatation. — Sterilize the canal and outlet in the usual 
manner. If there are no indications requiring hasty delivery and 
the external os will not admit the finger, immediate dilatation may 
be preceded for twenty-four hours by tamponade of the cervix with 
gauze, inserted with dressing forceps, the uterus being steadied by 
volsellum forceps. If the external os will not admit the finger at 
the time of operation, dilate with Palmer's or Goodell's metallic 
dilator sufficiently. Two methods of manual opening of the cervix 
are used : 

i . Harris method : Cone the hand, previously anointed with 
aseptic glycerin or lysol solution ; pass it into the vagina ; insert 



INDUCTION OF LABOR. 261 

one finger slowly by a boring motion into the uterine canal, making 
suprapubic counter-pressure at the same time to prevent extreme 
upward stretching of the vaginal attachments. As the cervix 
dilates, follow the first finger with the others successively and then 
with the thumb, until the full hand readily enters the cavity. 
The danger of lacerating the uterine outlet increases as dilatation 
advances, and therefore particular care is necessary toward the last 
of the process. This method has the especial disadvantage that 
the hand displaces the presenting part, which with vertex presen- 
tations is often undesirable. . 

2. Edgar method: One finger of each hand is inserted into 
the cervix and pulled in opposite directions, then two or three, 
until full dilatation is obtained; this mode is less tiresome to 
the operator than the other, but the cervix must often be opened 
for the finger by metallic instruments. The time required for 
manual dilatation depends upon the elasticity of the cervical ring, 
it being usually from forty-five minutes to an hour. Tearing of 
the outlet is prevented only by the greatest care, and the method, 
being quite dangerous for the unskilled operator, should be re- 
served for emergencies Lacerations from manipulation should 
be closed after extraction. 

Hydrostatic Dilators. — When delivery is not urgent, dilatation 
up to three inches may be obtained by using Barnes' or McLean's 
water-bags, or those of Champetier de Ribes, which being non- 
elastic, dilate more equally. Their further description or mode 
of use is unnecessary here. Important objections to Barnes' 
dilators are that the rubber spoils when kept for any length of 
time ; dilatation by them is unequal, most of it being within the 
uterus and vagina, least in the cervix; and they are almost never 
at hand when needed. Gauze tamponade is fully as serviceable 
when haste is not an object, and by softening the cervix better 
prepares the way for the hand. 

Duhrssen's Incisions. — By this method the cervix is incised, 
after the internal os is fully effaced, by straight scissors upon four 
sides, up to the vaginal junction, the incisions being sutured after 
extraction. It should be reserved for the gravest emergencies 
(like sudden death of the mother) and performed only by the ex- 
pert. 



262 THE PRINCIPLES OF OBSTETRICS. 

Summary of Methods. — Sterilization in the most thorough 
manner of operator, patient, and instruments is absolutely essen- 
tial to success. 

1. Krause's method by catheterization of uterine cavity is safe, 
slow, and unreliable, but best for the inexperienced. 

2. Tamponade of vagina is best adapted for hemorrhage; it is 
more certain than Krause's method, and anticipates 

3. Manual dilatation, which is certain, especially applicable for 
emergencies, but dangerous for beginners and lacerations are 
likely to result. 

4. Diihrssen's incisions are to be used only for the gravest 
emergencies by the expert. 

Various other methods, such as electricity, intra-uterine injec- 
tion of water, glycerin, etc., having been demonstrated to be un- 
safe and unreliable, will not be described. 

In the early weeks of pregnancy the uterus is best emptied, 
after opening it by Palmer's or Goodell's dilators, by the finger, 
curette, or placental forceps, followed by thorough irrigation, 
according to the method described for treatment of abortion. 

Treatment of the Immature Child — The immature child re- 
quires especial attention in order to keep it alive. The full bath 
should be postponed for several days, and artificial heat, supplied 
by hot-water bottles laid under or about it, the chances of its 
survival being much increased if it can be kept in an incubator 
(see page 188). One drachm of breast milk, whey, or cream and 
water may be given every hour with a medicine-dropper through 
the mouth, or with a narrow-pointed spoon through the nares. 
Fetal mortality after induced labor is high, being over thirty per 
cent. 



CHAPTER II. 



M 



FORCEPS. 

The forceps is practically a pair of steel hands, designed to 

draw the child out of the mother. The typical models, Simpson 

and Hodge, are improved patterns of the Smellie and Levret, 

themselves early modifications of the original 

Chamberlain instruments. Each has especial 

characteristics. The Hodge, representing the 

Levret, has the French pin lock, is a powerful 

tractor and compressor, but on account of the 

peculiar shape of the blades the child's head is 
very likely to be injured. 
The Simpson, representing 
the Smellie, has the English 
lock, its cephalic curve is pe- 
culiarly adapted to hold the 
head without wounding it, 
and it seldom slips if prop- 
erly applied. The pelvic 
curve is suitable for either 
high or low uses, and the 
handles are provided with 
projecting shoulders and cor- 
rugations by which greater 
power can be exerted in ex- 
traction than with the smooth 
handles of the Hodge. From the experience 
of the author, the Simpson model is best 
adapted for all-round work by the general prac- 
titioner, its lighter modification (the ordinary 
short forceps) being particularly suited for de- 
livery through the outlet. For convenience of 
263 




Fig. 123. — Hodge 
Forceps. 



Fig. 124, 

Forceps | 



Simpson 



264 



THE PRINCIPLES OF OBSTETRICS. 



sterilization, the forceps should be made entirely of metal, nickel- 
plated to prevent rusting, the nickel being renewed whenever it 
commences to scale, and protected from injury by being kept in 
a closed canvas bag when not in service. 

Axis-Traction Forceps. — One of the most important obstetri- 
cal discoveries of the last century was the axis-traction forceps, 

perfected by Tarnier in 1873. 
In this model power is applied 
through two secondary rods, 
each upper extremity attached 
to the heel of a fenestra, and 
the lower united by a movable 
cross-bar handle. The line of 
draught is from the base of 
the fenestras rather than from 
the tip of the handles, and 
therefore in the axis of the su- 
perior strait instead of against 
the inner face of the symphysis 
as in the ordinary instrument. 
A second advantage is that it 
permits the natural movements 
of flexion and rotation during 
descent. (See following page.) 
Traction Rods. — A most 
practicable substitute for the 
expensive and complicated Tar- 
nier, or any of its modifica- 
tions, are the traction rods of 
Reynolds. Provided with modern Simpson's long forceps and 
Reynolds', or similar traction rods, the general practitioner is 
ready for any emergency of labor requiring instrumental de- 
liver)-, craniotomy and other mutilating operations being ex- 
cepted. (See following page.) 

Function of Obstetrical Forceps. — Its chief function is traction, 
occasionally that of rotation (as in occipito-posterior positions), 
exceptionally as a lever (though the safety or usefulness of this 
method is questionable), and least of all compression (when it is 




Fig. 



-Tarnier Axis-Traction Forceps. 



F0BCEP8. 



265 



a question between forceps deliver} - with resulting dead child, or 
craniotomy). 

GENERAL INDICATIONS FOR FORCEPS. 

Defect in Powers. — The forceps is indicated for manifest weak- 
ness of natural forces in vertex presentations, and ordinarily during 




FIG. 126. — Line of Draught with Simpson Forceps 




Fig. 127.— Line of Draught with Axis-Traction Forceps. 




FIG. 12S —Reynolds' Traction Rods. Applied to Elliott model of forceps. 

the second stage when the head is stationary in the canal for two 
hours. Delivery of an impacted breech by forceps is advised and 
condemned bv equally good operators. 

Defect in Passages. — For rigidity of the soft parts of the canal, 
relative disproportion between passage and passenger, and when 



206 



THE PRINCIPLES OF OBSTETRICS. 



the true conjugate, in deformed pelves, is not less than three and 
one-half inches (9 cm.). 

Defect in Passengers. — For impaction in either occipito-poste- 
rior and anterior face positions, or breech presentations ( ?), for 
after-coming head, moderate degrees of hydrocephalus, or when 
auscultation shows that the fetal pulse is less than 100 and more 
than 160, and in complications which require immediate extraction, 
like placenta praevia, accidental hemorrhage, prolapse of funis, 
rupture of uterus, and eclampsia. 

GENERAL CONTRAINDICATIONS. 

Forceps is contraindicated when the cervix is not dilated nor 
dilatable (exceptions being in threatening uterine rupture, cardiac 



JP* 




■l 


fjmrnmm 


4B 





Fig. 129.— Walcher Position. Hips resting on edge of table. 



disease, and occasionally to assist dilatation by drawing the head 
against the external os), always with unruptured membranes, 
hydrocephalus, perforated head, or positions impossible for de- 



FORCEPS. 267 

livery (chin posterior), when the true conjugate is below three and 
one-half inches (9 cm.) and rarely before engagement. 

Preparation for Forceps. — As a rule, the necessity for forceps 
should be explained to the patient or near relatives and permis- 
sion granted. After the physician sterilizes his hands and arms 
in the ordinary surgical manner, the woman's external genitals 
are cleansed with green soap and hot water, and then rinsed 




Fig. 130. — Lithotomy Position. Thighs supported by twisted sheet. 

with lysol (one per cent) or bichloride (1 to 5,000) solution, vagi- 
nal antisepsis being omitted except when the canal is evidently 
infected. The forceps is boiled for ten minutes, and then trans- 
ferred to a pitcher of hot lysol solution, one per cent, until re- 
quired. If lysol is used, no other lubricant for the blades is 
needed, otherwise they should be anointed with sterilized vaseline 
or glycerin. When delivery is likely to be long, the patient's 
limbs should be protected by sheets, towels, or ordinary surgical 
drawers. Anaesthesia by ether is best for all cases, except for 
simple extractions at the outlet. 

Posture in Forceps Delivery. — In this country the ordinary 
obstetrical position is the dorsal, with hips resting upon the edge 
of the bed ; but the Continental, prone upon the left side, is often 
serviceable for low deliveries. For difficult extraction the bed 
can be exchanged to advantage for a common table; its height 



268 



THE PBIXCIPLES OF OBSTETRICS. 




Fig. 131.— Insertion of Left Blade of Forceps. 




Fig. 132.— Insertion of Right Blade of Forceps. 



FORCEPS. 



269 



relieves the necessity for the tiresome stooping posture for the 
operator, the thighs being supported by assistants, leg bandage, 
or twisted sheet. 

Walcher and Lithotomy Positions. — The conjugate diameter 
is unquestionably lengthened at the superior strait by placing the 
patient in the Walcher position (page 266) and at the outlet by 
the lithotomy, either being valuable adjuncts in hard deliveries 
at these respective situations. 






Fig. 133.— Both Blades Inserted at Middle Strait. Ready for use. 



Application of Simpson's Forceps. Vertex Presentation, 0. L. 

A. — This model of instrument and position of child are selected 
for illustration only. The correct application of forceps is much 
more easily learned under the practical guidance of a skilled oper- 
ator than from printed directions. Hold the left (lower, female) 
half by the first and second fingers and thumb of the left hand 
(just as one naturally uses a pen), vertically to the woman's body. 
Pass the first two fingers of the right hand within the cervix, be- 






270 



THE PBINCIPLES OF OBSTETRICS. 



tween the uterine wall and head, then push the tip of the blade into 
the canal along the palm of the hand, guiding it into the uterus 
upon the fingers, the latter being then withdrawn. As soon as the 
blade enters the uterus, hold the handle with full hand, pushing 
backward and upward as far as the perineum will permit, at the 
same time rotating the blade forward upon its long axis to pass 
the promontory, when it will usually glide upward and adapt itself, 
after a little manipulation, to the head. Repeat the process with 




FIG. 134. — Position of the Hands in Extraction. 



the right (male or upper) blade, the hands and mechanism being 
reversed from that used with the left. If the shanks do not lock 
readily, push each half upward, depressing the handles as much as 
possible, or push each blade sidewise upon the head by pressure 
of two fingers upon its posterior edge, until each adapts itself as 
nearly as possible over the biparietal diameter. 

Extraction. — Before commencing traction, re-examine to see 
if the blades are properly adjusted, and that no portion of the 
vulva nor strand of hair is included within the lock. Grasp the 



FORCEPS. 



271 



head firmly, but only tight enough to prevent slipping. In the 
latter case the handles must be unlocked, pushed backward and 
upward, and reclosed. Traction is made, if possible, only during 
pains, with corresponding intervals of rest, when compression is 
relieved by opening the handles or unlocking them, imitating in 
this manner the normal mechanism of labor. Each pull should 
not continue longer than one minute, except in especial emergen- 
cies which require hasty extraction. 

Hard-and-fast rules for grasping the handles are impracticable, 




Fig. 



-Diagram of Axis of the Superior Strait, Illustrating Indicated Line 
of Draught. 



since every one has more facility with one hand than the other. 
In high deliveries traction should be made in the axis of the supe- 
rior strait, as far back as the sphincter of the outlet permits, the 
hand nearest to the vulva pushing downward upon the lock while 
the other pulls forward by the handles. In low deliveries the line 
of draught is at first horizontal, then directly upward, until the 
handles lie upon the abdomen, so that the child's neck shall hug 
the pubic arch as closely as possible. Generally the stronger hand 
does the pulling, by grasping the handles with the fingers hooked 
over its shoulders, the weaker hand being accessory and placed 
above or below the other, with its index finger inserted between 



272 



THE PRINCIPLES OF OBSTETliK'S. 



the shanks within the vagina to note the progress of the head, 
the amount of pressure it is making against the symphysis, and 
whether the blades are slipping. Ordinarily forceps should be 
removed when the edge of the perineum begins to stretch over 
the anterior fontanel, delivery being completed by reflex action 
of perineal muscles. 

Other Details of Extraction. — Only that amount of strength in 
pulling is usually needed which can be exerted by the arms, brac- 




FlG. 136.— Method of Extraction at Outlet. 



ing the feet against the bed being unscientific and hazardous. 
Delivery from the upper strait will ordinarily require an hour or 
more, and from the lower a half hour or less, it being impossible 
to fix a distinct limit of time to a forceps operation on account of 
the varying character of the obstruction. Successful extraction 
depends much more upon skill than brute force, the idea being to 
coax out rather than drag out the head; and the amount of power 
exerted, as measured by a dynamometer, is rarely over fifty 
pounds. If any doubt should exist as to the proper line of 



FORCEPS. 



273 



draught, the handles, when freed from the grasp during pains, will 
point oat the correct direction. 

Application of Axis-Traction Forceps. — The blades are inserted 
in a similar manner to those of ordinary forceps, and fixed upon the 
head, after adjustment, by moderate closure of the binding clamp. 
The accessory rods, being freed from their attachment to the 
primary handles, are united by the cross bar, upon which traction 
is made in a direction as nearly as possible in the centre of the 




Fig. 137. Method of Delivery with Axis-Traction Forceps. 



axis of the superior strait (that is, backward and downward), until 
the head has descended well into the excavation. Injury to the 
perineum by the rods is prevented by interposing a Sims specu- 
lum or the fingers. When the head has reached the pelvic floor 
the axis-traction idea is unnecessary, and the instrument is handled 
similar to an ordinary forceps, or exchanged for Simpson's. 
18 



274 



THE PRINCIPLES OF OBSTETRICS. 



Axis-Traction Rods. — After the blades of the Simpson for- 
ceps are adjusted, each rod is hooked from within upon the lower 
edge of a fenestra, the forceps handles are closed by the clamp, 




FIG. 138. — Diagram Illustrating Line of Draught with Axis-Traction Forceps. 

the cross bar is attached, and traction made upon it just as with 
the Tarnier. 

Removal of Forceps. — The forceps is removed by reversing 
the method of application ; the right blade is withdrawn first over 
the opposite groin, rotating around the ramus upon two fingers 
interposed between the soft parts and its edge, and the left fol- 
lows in a corresponding manner. 



CHAPTER III. 
VERSION AND CESAREAN SECTION. 

VERSION. 

Version, or turning, is the artificial substitution in utero of 
one fetal pole for the other. There are four recognized meth- 
ods: (i) Posture of the mother; (2) external version; (3) com- 
bined external and internal, or bipolar version; (4) internal, or 
podalic version. Barnes says: "If we were restricted to one 
operation in midwifery as our sole resource, I think the choice 
must fall upon turning. Probably no other operation is capable 
of extracting patient and practitioner from so man}' and various 
difficulties" (Reynolds). Version is called "cephalic"' when the 
head is made to present, "pelvic" when the breech, and "poda- 
lic " when the feet. 

Indications. — The operation is chiefly indicated in transverse 
presentations ; then for contracted pelvis, especially in multiparas, 
because the base of the skull will more readily pass through the 
birth canal (already distended by previous deliveries) than the 
larger vertex ; when extraction must necessarily be hasty (placenta 
praevia, accidental hemorrhage, eclampsia, rupture of the uterus, 
embolism, and maternal death) ; in prolapse of cord or arm, and 
in unfavorable head presentations (brow, ear, etc.). 

Contraindications. — Version is absolutely contraindicated after 
firm impaction of the head and with high contraction ring, 
because in the latter condition manipulation is liable to cause ute- 
rine rupture; it is hazardous and compulsory rather than elec- 
tive in rigidity of the cervix and vagina, after prolonged discharge 
of liquor amnii, for the first of twins, and in fetal deformities 
like spina bifida, etc. 

275 



276 



THE PRINCIPLES OF OBSTETRICS. 



Favorable Conditions. — These are: membranes unruptured, 
dilated cervix and dilatable external os, thin abdominal walls, and 
normal tension of the uterus. The reverse of these conditions is 
distinctly unfavorable (eclampsia, very fat abdomen, etc.;. All 
manipulation in version should be confined to the intervals be- 
tween pains ; extraction, on the contrary, being made during them. 
To avoid repetition in description of technique, it is essential that 
the operation should be performed under the strictest asepsis of 
physician, patient, and passages. 

i. Version by Posture. — Unfavorable positions may be con- 
verted occasionally into favorable by turning the child in utero by 




FlG. 139. — Cephalic Version by External Method. 



force of gravity. Thus in impaction of the vertex flexion may be 
assisted by placing the patient upon that side toward which the 
child's face looks. 

2. External Method. — A transverse or breech presentation 
may be changed into a vertex by abdominal pressure only, push- 
ing upward upon the breech with one hand and downward upon 
the head with the other, and is likely to be successful if attempted 
before commencement of labor, when the membranes are intact, 



YERSIOX AXD CJESABEAX SECTIOX 



277 



abdominal walls thin, and uterus is relaxed. If the attempt is for- 
tunate, a firm binder should be applied over compresses arranged 
upon the sides of the uterus, so that a return to the original mal- 
presentation may be prevented. 

3. Combined or Bipolar Method (Popularly Called " Hicks 
Method.") — The woman is anaesthetized, placed in the dorsal posi- 
tion, and the operator seats him- 
self between her thighs, facing 
the vulva. The child, as a 
whole, is turned end for end 
by combined action of both 
hands, one external and the 
other internal. While the outer 
hand is pushing the breech 
downward, two fingers only of 
the other, inserted within the 
cervix, are pressing the head 
at the same time upward in an 
opposite direction. Force is ap- 
plied between pains, not con- 
tinuously but by a succession 
of pushes. To illustrate: The 
presentation being that of the 
vertex, the fingers within the 
uterus lift the head toward that 
side of the pelvis to which its 
occiput points, the external hand 
meantime depressing the breech 
in an opposite direction. As the shoulder comes within reach 
of the fingers it is also lifted, while the breech is still farther 
pressed downward, until somewhat lower than the original position 
of the head, and the knee descends within grasp of the fingers. 
At this stage of the operation the hands exchange their first point 
of pressure, the internal fingers drawing down the knee, and the 
external hand pushing the head well up to the fundus. The re- 
mainder of delivery is similar to that for a primary breech or foot 
presentation. 

In all shoulder presentations, cephalic version by the external 




FIG. 140. — Version by Bipolar Method. 



278 



THE PRINCIPLES OF OBSTETRICS. 



method is preferable to pelvic by 
the route, being shorter, can be 




Internal Version. Seizing a foot. 

tervals between pains. Should z 
while the hand is working 
within the cavity, all manipu- 
lation must cease until the 
uterus again relaxes. If an 
arm is found prolapsed, draw 
it down outside the vulva, 
where a strip of gauze should 
be placed about the wrist for 
a tractor, by which extension 
can be prevented during deliv- 
ery of the body. When the 
uterine cavity is entered, push 
the hand across the child's ab- 
domen and distinguish the feet 
from the hands (the foot has a 
heel and toes of equal length). 
Grasp the ankle of the nearest 



the combined method, because 
accomplished more easily and 
quickly, and is less dangerous 
in ultimate results for the 
child. 

Internal or Podalic Ver- 
sion. — This is the method of 
version most often used, and 
its successive details should 
be mastered. Full anaesthe- 
sia and a competent assistant 
are essentials to success. Place 
the patient in the lithotomy 
position, anoint the back, not 
the palm, of that hand whose 
palmar surface, when held mid- 
way between pronation and 
supination, faces the child's 
abdomen, and pass it through 
the external os during the in- 
contraction occur at any time 




Fig. 



142.— Internal Version. Drawing down 
the leg. 



YEESION AND CESAREAN SECTION. 



279 



foot with two fingers and the thumb, the heel resting in the palm ; 
draw downward and backward in the axis of the superior strait 
until the knee appears at the 
vulva, and at the same time 
push upward the head with the 
external hand. If the dorsum 
of the child was originally pos- 
terior, extraction should be 
combined with its anterior ro- 
tation. 

Podalic version is now com- 
pleted. Unless there are indi- 
cations for hasty delivery (pla- 
centa prsevia, prolapse of cord, 
or other emergency), the an- 
aesthetic may be removed and 
labor allowed to proceed spon- 
taneously until the umbilicus 
appears at the vulva, the re- 
maining manipulations being 
similar to those practised in an 
ordinary breech presentation 
(see Chapter III.). If, how- 
ever, as frequently happens, 
the conditions requiring podalic 
version are still present, birth 

should be completed at once, using such methods as have been 
described for original breech presentations. 




Fig. 



-Internal Version, 
grasping the foot. 



Method of 



CESAREAN SECTION, OR COELIOHYSTEROTOMY. 

It is not expected that Caesarean section will ordinarily be 
performed outside of hospitals, or by other than expert surgeons. 
Nevertheless it may be required at any time of the general prac- 
titioner, especially in the country, at a distance from skilled con- 
sultants. In such emergency he should not be deterred, by in- 
experience with capital abdominal surgery, from attempting to save 
life, remembering that the operation has been successfully made 



280 THE PRINCIPLES OF OBSTETRICS. 

bv the ordinan' physician under the most unfavorable conditions 
of time, place, and environment, and with unprofessional assistants. 

The latest text-books upon obstetrics fully describe the indica- 
tions for and technique of Caesarean section, and from these the 
present condensed method is offered as a practical working guide. 

When the child is delivered through an incision into the abdo- 
men and uterus, the operation is called " Caesarean section," from 
the Latin, cceso matris utero. 

Indications. — The indications are either: (i) "absolute," 
when some condition of the birth canal absolutely prevents deliv- 
ery through it, or (2) "relative," when it is a question whether 
Caesarean section or some other method of delivery is relatively 
best for the mother and child. Absolute indications are the nar- 
rowing of the brim below two and a half inches (6.5 cm.), as in 
extreme degrees of pelvic deformity, obstruction of the canal by 
tumors, stenosis of vagina by cicatrices and carcinoma, inoperable 
cancer of the cervix, and, by a few laparotomists, placenta praevia 
centralis. Relative indications are when the true conjugate in 
deformed pelves is more than two and a half inches (6.5 cm.), and 
delivery is possible by the alternatives, symphyseotomy, forceps, 
version, or craniotomy. Williams believes that in uninfected cases 
the upper limit for the absolute indication for Caesarean section 
should be advanced from 5.5 cm. to 7 cm., and for relative indica- 
tion from 7 or 7.5 cm. for flat pelves and 9 cm. for those generally 
contracted* 

Varieties ot Method. — From different modifications of the 
primitive operation but two are practically retained at present : (1) 
The Sanger, distinguished by an especial mode of applying the 
sutures; and (2) finishing the section by an hysterectomy. 
When the operation is made for absolute indication, and a second 
pregnane}- might occur which would require its repetition, the 
uterus is ordinarily amputated, but for relative indication hyster- 
eetomy may or may not be performed, according to the wishes of 
the woman or her family or the preferences of the operator. Gen- 
erally, however, the necessity for a second section is negatived by 
the removal of the uterus, tubes, and ovaries. 

* American Journal of Obstetrics, September, igoi. 



VERSION AND CESAREAN SECTION. 281 

Time for Operation. — The operation is " elective " when it is 
performed at a selected period of gestation, during the daytime, 
and after all preparations of patient, assistants, and place of opera- 
tion have been completed, and " compulsory " after other plans of 
delivery have failed, the patient has become infected, and in other 
grave emergencies. Williams says (see paper already quoted) 
that with absolute indication it should be made either at the onset 
of labor or at the end of pregnancy; with relative indications the 
woman should be allowed to enter the second stage of labor and 
have bearing-clown pains for an hour, when, if the head shows no 
signs of moulding or descent, Caesarean section should be made 
instead of forceps used on the movable head or version. On the 
other hand, if the patient is infected, or her surroundings are such 
that an aseptic operation cannot be made, high forceps or version 
should be attempted, followed by craniotomy in case of failure by 
these means, Caesarean section being reserved for those cases in 
which an absolute indication is present on the part of the pelvis. 

Contraindications. — Child dead, mother infected after long at- 
tempts at delivery, unfavorable environment for operation, or in 
extremis from shock, hemorrhage, rupture of uterus, etc. 

COMPARISON BETWEEN CESAREAN SECTION, SYMPHYS- 
EOTOMY, AND CRANIOTOMY. 

True conjugate below two and half inches (6.5 cm.): Living 
child, aseptic operation, mother in good condition ; elective opera- 
tion is Caesarean section. Child dead ; mother infected ; previous 
attempts at delivery ; craniotomy. 

True conjugate above two and a half inches (6.5 cm.): Child 
living, mother in favorable condition, forceps or version for inex- 
perienced operator, Caesarean section or symphyseotomy for expert. 
Child dead, mother infected, craniotomy elective operation. 

Technique of Operation. — Preparatory. — Anticipate operation, 
if possible, by tonics, diet, catharsis, nerve sedatives, and hygienic 
measures. When it is to take place in a dwelling, cleanse room by 
washing paint, remove carpet, ornaments, and all furniture except 
the bed. On the night preceding the operation, have the patient 
take a full bath ; then cover the abdomen with green soap poultice 






282 THE PRINCIPLES OF OBSTETRICS. 

for three hours ; scrub with green soap, bichloride ( i to 2,000), and 
alcohol ; cover with sterilized compress and abdominal bandage. 

Morning of Operation. — Resterilize the abdomen and birth 
canal; if the patient is feeble fortify by hypodermic of strychnine, 
one-thirtieth of a grain, and nutrient enema of milk and whiskey. 
Place the woman on a suitable table, which is protected by a quilt, 
rubber sheet, and sterilized sheets, covering her extremities and 
body (except in line of abdominal incision) with warm flannels. 
Just previous to beginning the operation catheterize with sterile 
instrument in aseptic manner. 

Assistants. — One to stand opposite and assist operator ; one for 
handling instruments, sutures, and dressings ; one for anaesthesia, 
and a competent nurse to receive and care for the child. All except 
the nurse are sterilized in the most careful manner. 

Instruments. — Select instruments for an ordinary laparotomy : 
scalpel, straight scissors, twelve haemostats, a needle-holder, curved 
needles with large eye for catgut, sponge forceps, one-half-inch 
rubber tubing for constricting neck of uterus, satisfactory catgut 
in unopened bottles (small, medium, and large sizes), twelve silk- 
worm gut sutures for closing abdomen, twelve packing-off gauze 
pieces, several dozen gauze sponges, a Spencer Wells clamp, and 
abdominal retractors. Sterilize all metallic instruments in an 
Arnold sterilizer at the physician's office, or at the house in an 
ordinary steamer upon the kitchen stove, or by boiling in a suit- 
able vessel in soda water for half an hour; gauze is sterilized 
by baking or steaming an hour. 

Operation. — Abdominal lncisioii. — Incise in the median line, 
without haste, down to the peritoneum, all bleeding vessels being 
immediately caught with haemostats. The incisison should be six 
inches long, or long enough to permit the eventration of the 
uterus, beginning just below the umbilicus, and extending within 
an inch of the pubis ; or the upper third may be above the umbili- 
cus and the lower extremity two or three inches above the pubis. 
After opening, divide peritoneum with scissors upon the finger 
to equal length, deliver the uterus outside the abdomen, placing 
gauze packing behind it to protect intestines and absorb dis- 
charges. Have an assistant inject deep into the outside of the 
thigh one-half drachm of fluid extract of ergot. If the first as- 



VERSION AND CESAREAN SECTION. 283 

sistant is reliable, let him grasp the neck of the uterus with both 
hands to control hemorrhage, or, if preferred, pass a loop of tub- 
ing about it, which may or may not be tightened, as hemorrhage 
requires. 

Uterine Incision. — Open the uterus quickly in the median line 
near the fundus, tear by finger or cut with scissors down to the 
inner os or retraction ring. If the placenta presents in the uterine 
opening, pass the hand by its edge, rupture the membranes, 
extract the child by either its hand or feet, catch the cord between 
two haemostats, sever, place the child in a sterile towel, and give 
it to the nurse. Extract the placenta, if not already separated, 
with the hand. Dilate the cervix with the finger to provide for 
drainage. Wiping or irrigation of the cavity is unnecessary. 
Contractions usually follow delivery, but if they are feeble they 
should be stimulated by manipulation through a hot towel. 
Hemorrhage, which is ordinarily slight, is controlled by manual 
compression about the cervix or by tightening of the tubing. 

Uterine Sutures. — Deep interrupted sutures of medium-sized 
catgut are inserted about one-third of an inch apart and one-half 
an inch from the edge of the incision, passed obliquely inward and 
downward, not including the mucous surface, and outward in the 
same manner. The uterine peritoneum and the upper layer of the 
muscular wall are closed by interrupted or running stitch of small 
catgut. 

Packing-off pieces behind the uterus are then removed, and 
the uterus is returned into the abdominal cavity, any blood or 
liquor amnii remaining after their withdrawal being gently wiped 
out with gauze upon a sponge holder. 

Abdominal Sutures. — The abdominal wound is then closed in 
the ordinary manner after a laparotomy ; the peritoneum by run- 
ning stitch of small catgut, silkworm gut passed every two-thirds 
of an inch from within outward through all layers but the peri- 
toneum, the fascia united by running stitch of medium catgut, silk- 
worm gut tied, and superficial skin sutures placed between them 
if necessary. The abdomen is then cleansed and covered with a 
layer of gauze, absorbent cotton, and cheese cloth, all being 
retained in place by two-inch wide strips of adhesive plaster. 

Hysterectomy. — When elected before operation, the uterus 



284 THE PRINCIPLES OF OBSTETRICS. 

is amputated in the usual manner; the broad ligaments are 
clamped and sutured as they are cut away, the peritoneal flaps 
are prepared, the uterus is removed, and the stump is covered 
with peritoneum. 

After-Treatment . — The after-treatment is similar to that of an 
ordinary laparotomy ; if there is much hemorrhage during the oper- 
ation or resulting shock, enemata of decinormal salt solutions, and 
hypodermics of strychnine are indicated ; if pain is severe give a 
single hypodermic of morphine or codeine, catheterize every eight 
hours if necessary, and direct dessertspoonfuls of hot water every 
hour, with liquid diet after twelve hours as usual. Salines are 
given on the second or third day after operation, sooner if there 
are signs of infection. Silkworm gut sutures are removed at the 
end of two weeks, a firm binder is applied, and the bed may be 
left after three or four weeks. The child is nursed as after nor- 
mal labor, its subsequent management being regulated according 
to general principles. 



CHAPTER IV. 

SYMPHYSEOTOMY AND EMBRYOTOMY. 
SYMPHYSEOTOMY. 

An operation which increases the diameters of the superior 
strait by division of the symphysis pubis, the child being after- 
ward delivered through the natural birth canal. It was first per- 
formed upon the living woman by the Italian Sigault, in 1777, 
and repeated for several following years by other surgeons, but 
owing to the great mortality of the mothers from septic infection 
and injuries to the soft parts from unskilful delivery it was at 
length abandoned. Revived in Italy in 1S66, more favorable 
results, when performed under modern aseptic methods and 
obstetrical knowledge, have led to the general adoption of the 
operation throughout the world. 

Indications for the Operation. — Symphyseotomy is midway 
between Caesarean section and the less dangerous methods of de- 
livery: craniotomy, induced labor, either premature or at term, 
forceps or version. It is preferable to embryotomy when the 
conjugate is too small for delivery by version or induced labor, 
and yet large enough for other alternatives than Caesarean sec- 
tion. Experiments upon the living woman and cadaver show that 
separation of the pubic articulation to the extent of two and three- 
quarter inches thereby increases the antero-posterior diameter one 
and one-half inches, the transverse one and one-quarter inches, and 
the diagonal one and one-half inches, the conjugate diameter being 
further slightly lengthened by insertion of the parietal boss be- 
tween the divided ends of the pubic bones. With the living child 
it is the alternative of version in flat contracted pelves with a 
conjugate of over two and three-quarter inches (7 cm.), and in 
irreducible occipito-posterior, mento-posterior, and brow positions. 

Contraindications. — These are a dead child (delivery of which 

2S5 



286 THE PRINCIPLES OF OBSTETRICS. 

should be by craniotomy), ankylosis of either or both sacro-iliac 
articulations, and generally equally contracted and kyphotic pelves. 

Prognosis. — The maternal fatality under modern methods of 
operation is about the same for symphyseotomy and Caesarean 
section with similar conditions, fetal mortality being greater in the 
former than in the latter. Among its unfavorable results are 
lacerations of the vagina, urethra, and bladder, hemorrhage, and 
less frequently injury to the sacro-iliac articulations or necrosis of 
the symphysis, although ordinarily the joint is perfectly restored. 

Varieties of Incision. — Two methods of incision are used: the 
French or open, in which a long incision is made upon the ante- 
rior surface of the symphysis, and the Italian or subcutaneous, in 
which the joint is opened subcutaneously through a short abdomi- 
nal opening. The open method has the advantage of being made 
under inspection ; the other is claimed to be less liable to infec- 
tion from the lochia. 

Technique of Operation. — Labor should be allowed to continue 
for twenty-four hours, when, after failure to deliver by a tentative 
use of axis-traction forceps or traction rods attached to the ordi- 
nary model, and under the indications already given, symphyse- 
otomy may be performed. The patient is prepared as if for a 
laparotomy, the vagina and the external genitals being sterilized 
together with the abdomen. She is then placed upon her back, 
anaesthetized, the thighs supported by a leg bandage, the hips 
steadied by assistants, the bladder emptied, and the cervix fully 
dilated, if not so previously. With a capacious and distensible 
vagina, lacerations are not so likely to occur as when rigid or nar- 
row. The urethra and neck of the bladder are pushed backward 
and usually to the right by an assistant with a metallic catheter, 
which also keeps the bladder empty. 

Subcutaneous Method. — An incision, about one inch long or 
more (depending upon the amount of subcutaneous fat) is made in 
the median line of the abdomen, ending just above the upper edge 
of the symphysis, whose upper border is exposed by careful dis- 
section ; a transverse cut, large enough to admit the index finger, is 
made to detach the recti muscles, and the tissues behind the joint 
are pushed back. A strong curved director is passed from above 
downward close to the joint to protect the clitoris and adjacent 



SYMPHYSEOTOMY AND EMBRYOTOMY. 287 

soft structures from injury, a large blunt-pointed bistoury passed 
along the director, and the articulation divided by a rocking up- 
ward and forward motion. If the joint is ossified or its line of 
union irregular, division is accomplished with a metacarpal or 
chain saw. Any decided hemorrhage after incision should be 
checked by firm packing of the wound with sterilized gauze. Dur- 
ing the incision assistants should hold the patient's thighs as 
steadily as possible and equally distant from the median line. 
After the joint separates, labor may be allowed to proceed spon- 
taneously, or, in vertex presentations, the head may be extracted 
immediately by axis-traction forceps or by an ordinary model, es- 
pecial care being taken to prevent laceration of the anterior vag- 
inal wall. During extraction each half of the pelvis should be held 
firmly by the assistants in order to prevent too great a separation 
of the pubic bones, and consequent injury of the sacro-iliac joints. 

After-Treatment. — After completion of the third stage, the 
lower extremities are laid flat upon the bed and the knees brought 
together. The operator resterilizes his hands, removes the gauze 
pack, and brings the severed bones into apposition, taking care 
not to permit the bladder to become pinched between them. 
Some authorities advise suturing the ends of the divided bones 
with silver wire, others unite only the fascia and periosteum with 
silk, silver wire, or silkworm gut, and still others reject all direct 
suturing of the symphysis. The abdominal wound is then closed in 
the manner usual after laparotomy, covered with gauze, several 
broad strips of adhesive plaster are passed obliquely from one hip 
to the other, and a strong binder is applied over all. 

Care of the patient during the puerperium is somewhat trouble- 
some, owing to the difficulty in preventing the wound from becom- 
ing infected. The catheter is usually required, and after its use a 
bed pan should be placed under the hips, followed by cleansing the 
external genitals with a solution of lysol, one-half of one per cent, 
or bichloride, i to 5,000. Various forms of apparatus have been 
devised for immobilizing the joint while union is taking place, but 
it is commonly sufficient to place the woman upon a moderately 
hard mattress and to confine the pelvis with ordinary adhesive 
plasters ; bags reaching from the axillae to the ankles are gener- 
ally placed upon either side of the body. The patient should be 



288 THE PRINCIPLES OF OBSTETRICS. 

kept in bed for at least six weeks and some form of pelvic bandage 
worn for several months after resumption of the usual occupation. 
Ayres' Method. — A modification of the subcutaneous method 
is practised by Ayres, who passes a narrow sharp-pointed bistoury 
underneath the clitoris through the mucous membrane from be- 
low; the joint is then opened with a blunt-pointed bistoury, the 
bladder and urethra are pushed aside with a sound, while a finger 
within the vagina controls the point of the knife during incision. 

EMBRYOTOMY. 

Embryotomy is a general term for all mutilating operations 
upon the foetus, including craniotomy, decapitation, evisceration, 
and amputation. 

Indications. — The most frequent indication for embryotomy, 
as has been stated in preceding pages, is prolapse of the cord and 
contracted pelvis ; next in order come hydrocephalus, when after 
perforation and discharge of cranial fluid the head is too large 
for delivery ; obstructed labor with dead child or monstrosity ; im- 
pacted shoulder or face presentation with dead child. 

Craniotomy. — In the great majority of cases, when embryotomy 
is indicated, the elective operation is craniotomy, which presup- 
poses a dead child, although exceptionally it may be proper for 
one which is living. In this connection the words of Hirst are 
pertinent: "In cases of difficult labor, if the pelvis is contracted 
or the child overgrown, and the physician must make a choice 
between Caesarean section, symphyseotomy, or craniotomy, if he 
has no skill in surgical work and is unable to procure expert as- 
sistance, it is better unquestionably to sacrifice the child for the 
mother's sake, rather than to attempt a serious surgical operation, 
amid unfavorable surroundings, and performed by an unskilled 
operator whose mortality must be great." 

Craniotomy is divided into three stages: (i) Perforation of 
the head; (2) removal of the contents; and if necessary (3) ex- 
traction of the lessened head. 

Instruments Required. — A perforator, either that of Smellie, 
a long pair of sharp-pointed surgical scissors, or a trephine ; Simp- 
son's cranioclast (head seizer), which has two blades, one for plac- 



SYMPHYSEOTOMY AXD EMBRYOTOMY. 



289 



ing inside and the other outside the skull, and handles furnished 
with a binding screw to fix the blades upon the head, or a pair of 
ordinary strong grasping forceps ; a cephalotribe (head crusher), 
the popular American model being that of Lusk, the blades of 




which are applied in a similar manner to the ordinary obstetrical 
forceps, and the head then crushed by slowly closing the screw at 
the handles ; strong volsellum forceps, and a large metallic cathe- 
ter to comminute the brain and through which to wash it out. 




Fig. 145. — Perforator of Simpson. 



Technique of Operation. — The patient should be anaesthetized, 
placed in the lithotomy position with the hips brought well down to 
the edge of the table, the rectum and bladder emptied, and all de- 
tails of sterilization scrupulously observed. The head is fixed in 




Fig. 146.— Cephalotribe of Braun. 

the brim by suprapubic pressure, and drawn as far into the vagina 
as is possible with volsellum forceps caught into the scalp. The 
fingers are then passed up to the head, a suture or fontanel distin- 
guished, through which the perforator is thrust and opened widely 
19 



290 



THE PRINCIPLES OF OBSTETRICS. 



in various directions. It is next passed deeply into the cranial 
cavity and rotated sufficiently to break up the brain, particularly 
the medulla, destruction of the latter assuring the death of the 




child. The after-coming head may be perforated through a skin 
incision at the base of its neck, behind the ear, through the roof of 
the mouth, or any other accessible point. After perforation the 
catheter is passed inside the skull, and the comminuted brain sub- 




FlG. 148— Cranioclast of Simpson. 



stance washed out by bichloride solution, 1 to 5,000, from a bulb 
or fountain syringe. 

In extreme cases of pelvic obstruction by deformity or tumors, 
it may be necessary to reduce still further the size of the head by 




Fig. 149.— Braun's Hook. 

a crushing instrument, which in the large majority of cases should 
be a cranioclast. The inner blade is passed through the per- 
foration inside the skull, and the outer, which is inserted in a simi- 



V 



SYMPHYSEOTOMY AND EMBRYOTOMY. 291 

lar manner to that of an ordinary forceps, applied to its exterior. 
The handles, after being locked, are tightly fastened by the 
screw to the head, which is then extracted in the usual manner. 
In vertex presentations of the hydrocephalic head, simply empty- 
ing it is often all that is required for spontaneous delivery; in 
breech presentations the cranial fluid may be emptied, when nec- 
essary, by puncture through the spinal canal, or by other methods 
described on page 250. 

Decapitation. — The principal indication is an impacted shoul- 
der, when version is either impossible or dangerous because of 
the liability of rupturing the uterus during its performance. The 
neck may be severed either with ordinary long surgical scissors, 
whose points are guarded by two fingers of the other hand, an 
assistant having previously drawn down the neck with a blunt 
hook or fillet ; an ecraseur, furnished with piano wire or well-oiled 
strong cord; or chain-saw. A quicker and safer instrument is 
Braun's hook, passed flatwise up to the neck, and turned across 
it, decapitation resulting from backward and forward movements 
of the handle. 

Extraction of Decapitated Head. — The best method of extract- 
ing a severed head is by making strong traction upon the lower 
jaw with two fingers hooked upon it, while the other hand is 
pushing down the head by suprapubic pressure. In extreme pel- 
vic contraction the head may need to be crushed before it can be 
delivered. During extraction of the crushed skull it is important 
to guard against wounding the vagina by projecting fragments, 
and the operator should remember that rupture of the uterus is 
especially likely to occur while any of these methods of embryot- 
omy are performed. 

Evisceration and Amputation. — These operations are required 
exceptionally for impaction of the trunk or fetal monstrosity, and 
may be performed with ordinary surgical scissors, the viscera and 
amputated portions being afterward extracted by the fingers or 
strong grasping forceps. 



PART VIII. 

ACCIDENTS COMPLICATING 
LABOR. 



CHAPTER I. 
PLACENTA PREVIA AND ACCIDENTAL HEMORRHAGE. 

The most frequent and important accidents which complicate 
labor are hemorrhage from the uterus and lacerations of the canal, 
exceptionally rupture and inversion of the uterus, fractures and 
diastasis of the pelvis, and sudden death from various causes. 

HEMORRHAGE. 

Hemorrhage during the first and second stages of labor occurs 
from placenta praevia, premature detachment of a normally situ- 
ated placenta, rupture and inversion of the uterus, lacerations of 
the lower portion of the canal, and haematoma ; during and follow- 
ing the third stage from inertia uteri, adherent placenta, lacer- 
ations, rupture of vessels, and haematoma. 

Hemorrhage from placenta praevia is called "unavoidable," and 
that from premature detachment of a normally situated placenta, 
"accidental." These names originated with Rigby in 1789, and 
though not strictly correct, because based upon a wrong pathology, 
are still retained in obstetrical nomenclature. 

Placenta Praevia. — The placenta is praevia, as stated by Rigby, 
when it develops " at that part of the womb which always dilates 
as labor advances." If the implantation entirely covers the inter- 
nal os it is distinguished as "complete"; or "incomplete," if the 
internal os is only partially covered. These irregularities are 
subdivided into the very rare form of centralis, when the center 
of the placenta rests upon the internal os; partialis, when the 
larger part lies upon one side, usually the left, of the lower uter- 
ine segment, though the os is entirely covered ; marginalis, when 
only a placental edge lies upon it ; and lateralis, when an edge is 
present in the canal only after full dilatation, the two last forms 
being most common. 

Frequency. — Placenta praevia is estimated to occur about once 

295 



296 



THE PRINCIPLES OF OBSTETRICS. 



in a thousand labors, and four times more often in multipara than 
in primipara. 

Etiology. ^The exact cause is doubtful, but theoretically it is 



any condition of the decidua which allows irregular fixation of the 
ovum. It is most frequently associated with an endometritis, 
t'hen with abnormal positions, low down, of the tubal orifices ; with 

the congestion which accom- 
panies uterine fibromata and 
carcinoma ; with malforma- 
tions in development of the 
uterus, or exceptional!}- en- 



largement of its cavity, and 
with multiple pregnancies. 

Characteristics of Different 
Forms. — In placenta centralis 
and partialis hemorrhage be- 
gins earh", is abundant, and 
often repeated ; the descent of 
the child is retarded by the 
placental bulk, and labor is 
more dangerous than in other 
forms. Placenta lateralis and 
marginal is are most frequent 
forms, hemorrhage occurs af- 
ter labor is well advanced, or 
may be entirely absent dur- 
ing the first and second stages, but profuse in the third. 

When praevia, the placenta is usually broad, thin, and of irregu- 
lar shape, placentae succenturiatae being common ; the portion near- 
est to the os is thinnest because at this point the decidua is most 
deficient, infarction is probable, and it is often adherent. 

Clinical History. — The more central the implantation the ear- 
lier the hemorrhage, which is derived mostly from the uterus, but 
partially from the placenta. The greater the hemorrhage during 
pregnancy the more likelihood of serious flooding in delivery. 
Ordinarily bleeding is absent in the first months, but appears at 
the seventh or eighth month; exceptionally it is delayed until 
term. Beginning - suddenly, sometimes from a definite cause like 




Fig 



PLACEXTA PREVIA AND HEMORRHAGE. 297 

an injury, it usually stops spontaneously, and rarely there is con- 
tinual leaking ( still iridium). The flow is greatest just at the 
close of a contraction, absent during it, and may be checked en- 
tirely by pressure of the descending part against the placental 
site. 

Diagnosis. — -Diagnosis of placenta praevia is impracticable by 
external examination, owing to its peculiar absence of bulk and 
density, though it would rationally be suspected from the charac- 
teristic hemorrhage. By vaginal examination the cervix and vagi- 
nal vault are sometimes found soft and boggy, but the diagnosis is 
established as soon as the cervical canal admits the finger when 
the spongy placenta or membranes can be distinguished. The ma- 
ternal surface is uneven from the presence of the cotyledons, and 
a gritty feel differentiates it from a blood clot, membranes, or pre- 
senting part. Pulsating vessels are felt about the cervix, which 
together with the external os is dilated, and through the canal may 
be recognized the soft mass if the placenta is central, or an edge if 
it is lateral. When the round ligaments are not felt either in 
front or on the side of the uterus, placenta praevia is probable. 

Influence upon Labor. — Labor usually follows hemorrhage and 
is premature. Pains are feeble and irregular, because from ob- 
liquity of the fetal axis the normal stimulus to dilatation caused 
by pressure upon the lower segment of the presenting part is ab- 
sent. Moreover, the great vascularity of the placental site re- 
tards descent and therefore dilatation. Malpresentations, particu- 
larly transverse, are much more frequent than under normal 
placental conditions, and prolapse of the cord is likely. Maternal 
danger, post partum, is threatened from adherent placenta, uterine 
inertia, hemorrhage, and sepsis, abortion or miscarriage being es- 
timated as high as from forty to sixty per cent. 

Cause cf Hemorrhage. — Whenever the placenta is implanted 
upon that portion of the uterus which must be dilated to permit 
of the descent of the presenting part, blood-vessels are inevitably 
ruptured during the process. But through absence of normal 
mechanism for haemostasis, bleeding will continue until checked 
either by syncope, thrombosis, some part of the child, or artificially 
by tampons. In placenta praevia, the venous pressure from above 
is greater than under natural conditions, and therefore hemorrhage 






298 THE PRINCIPLES OF OBSTETRICS. 

is set up from any slight cause, even striking of the child against 
it from above. 

Prognosis. — Under modern aseptic technique, the maternal 
mortality is very much less than formerly, depending obviously 
upon the amount of hemorrhage. The more central the implan- 
tation the greater the danger, and death results more from the 
sequelae than from mere delivery. Danger increases with the 
duration of pregnancy, the immediate causes of death being 
hemorrhage, shock, thrombosis, and septic infection. Fetal mor- 
tality is enormous, being fifty per cent and over, from asphyxia, 
feebleness from prematurity, and stress of operative delivery. 

Treatment. — If recognized before viability, the treatment in 
general is similar to that for abortion or miscarriage. When pro- 
fuse hemorrhage, a dead foetus, or placenta centralis is present, 
empty the uterus at once. 

After Viability. — -As soon as placenta praevia is detected after 
the seventh month, deliver at once, according to the following 
method : Obtain a reliable assistant ; anaesthetize the woman and 
place her in the lithotomy position. After sterilizing the entire 
birth canal, dilate the cervix, if necessary, manually by either the 
Harris or Edgar method. Insert the finger into the uterus and 
feel for an edge of the placenta. Separate the membranes around 
the internal os as high as possible with the finger, and make com- 
bined bipolar version (page 277), rupture the membranes, and 
draw down one foot until the knee appears at the vulva. Hemor- 
rhage usually stops as soon as the breech fills the brim, and further 
progress may be commonly left to natural forces, pains being 
stimulated by occasional traction upon the leg, and plenty of time 
given for dilatation. If labor is not completed naturally in an 
hour, extract the child. 

If bleeding is found to be profuse at the first visit, or should 
suddenly happen before full dilatation, tampon immediately, wait 
an hour for the cervix to open, then deliver as directed ; or if it is 
a vertex presentation, use forceps and immediate extraction, pro- 
vided there is sufficient dilatation. With placenta centralis, the 
ordinary method of delivery is by perforation with the hand and 
podalic version, extracting the child directly through the placental 
opening. 



PLACENTA TBMYIA AND HEMORRHAGE. 299 

It is proper to state that some, particularly foreign, authorities 
object to immediate extraction after podalic version, but in the 
practice of the author this method has been almost universally 
successful. The tampon is not reliable as an haemostatic ; even if 
no blood appears at the vulva during its use hemorrhage may con- 
tinue inside the uterus. It is difficult to apply efficiently, distresses 
the woman, and promotes sepsis. Slight cases of flooding maybe 
arrested by the tampon and temporizing, but it is rarely possible 
to determine the exact amount of malposition; and it is well 
established, clinically, that hemorrhage itself is no criterion of the 
degree of praevia present. Full anaesthesia and thorough tech- 
nique should neutralize the risk of operation, which is principally 
shock. 

Management of the Third Stage. — Acute anaemia requires ele- 
vation of the foot of the bed, stimulation by dry heat to the ex- 
tremities, small quantities of hot drinks, particularly ordinary tea 
without milk, hypodermics of strychnine, gr. ^ every fifteen min- 
utes for an hour, trinitrin gtt. -,\ often, ergotole gtt xv., ether, 
and especially morphine, gr. % p. r. n. Enemata of normal salt 
solution, six-tenths of one per cent (one teaspoonful to the quart) 
are very valuable, because of the stimulating action of the heat, 
and large quantities of fluid are quickly absorbed into the depleted 
vessels. Clinical experience demonstrates that its use per rectum 
is as serviceable as by subcutaneous injection, and much safer. In 
exceptionally desperate cases the normal salt solution may be in- 
jected directly into the median basilic vein, provided there is time 
for proper sterilization of patient, operator, and solution ; but this 
method and the subcutaneous injection are better after immediate 
danger is over, when the proper technique can be observed. 

Caesarean Section for Placenta Praevia. — Some of the leading 
American gynaecologists and obstetricians advocate Caesarean sec- 
tion and hysterectomy " in all cases of placenta praevia, central and 
complete, and especially so when the patient is a primipara, when 
the os is closed and cervix unabridged ; when hemorrhage is pro- 
fuse and cannot be controlled by tampons and separation of the 
placenta around the internal os is difficult or impossible." * 

* Zinke : American Journal of Obstetrics and Gynecology, October, 1901. 



300 



TILE PRIXCIPLES OF OBSTETRICS. 



This method would be impracticable for the ordinary practi- 
tioner, unless he could avail himself of the services of an expert 
laparotomist. 

Accidental Hemorrhage. — Very little was definitely known of 
this anomaly of gestation until Goodell, in 1869, wrote his classical 
monograph, founded upon the study of one hundred and six cases. 
Since that date the list of cases has been much enlarged, and the 
pathology of the condition is now well understood. 

Frequency. — It is somewhat infrequent, many obstetricians 
never having observed it, even in large practice. 

Etiology. — The cause is in general any condition of the decidua 
which permits separation of the placenta before the natural time 
at the end of labor, resembling therefore 
that for abortion. There is an apparent 
association of cause and effect between 
accidental hemorrhage and external vio- 
lence, severe physical exertion, constitu- 
tional diseases like nephritis, pneumonia, 
etc., congestion of the pelvic vessels, dis- 
ease of the decidua and placenta, short 
cord, and multiple gestation. 

Two varieties are distinguished: (1) 
apparent, when the effused blood breaks 
through the membranes and appears at the 
vulva; and (2) concealed, when (a) the 
centre only of the placenta is separated; 
(#) when the upper margin only is de- 
tached and hemorrhage is between the 
membranes and uterine wall ; (Y) when the membranes are torn 
at a distance from the internal os and blood is mixed with liquor 
amnii; and (d) when the cervical outlet is obstructed by coagula. 
Symptoms. — Hemorrhage begins either ante partum or early 
in the first stage, contractions gradually cease, and there is more 
or less severe pain at placental site. Presently appear signs of 
internal hemorrhage, indicated by shock, rapid and feeble pulse, 
fainting, etc., the uterus becoming distended by accumulation of 
blood, which may be localized by bulging at the normal site of the 
placenta. Fetal heart sounds grow indistinct, and blood}' liquor 




Fig 



Hem- 



PLACENTA PREVIA AND HEMORRHAGE. 



301 



amnii is discharged. Exceptionally accidental hemorrhage takes 
place as early as the fourth month, with or without abortion as a 
result. 

Diagnosis. 



Accidental hemorrhage. 


Ruptured uterus. 


Placenta praevia. 


Hemorrhage 


Hemorrhage 


Accepted or excluded 
bv vaginal examina- 










tion. 


Shock 


Shock. 

Sudden extreme pain? 




Sudden extreme pain?. . 




Early in labor 


Late in labor. 




Membranes unruptured. 


Membranes broken. 




No recession of present- 


Recession of presenting 




ing part. 


part. 




Uterus distended in con- 


Uterus firmly contracted. 




cealed hemorrhage. 


Blood possibly dis- 
charged into abdomi- 
nal cavity. 





Prognosis. — The apparent variety is not so dangerous to the 
mother as concealed, in which the mortality is fully fifty per cent. 
Fetal mortality is enormous, ninety per cent, death resulting 
usually from asphyxiation. 

Treatment. — The only safe treatment is immediate delivery 
whenever the emergency is discovered, because there is no possi- 
bility of arresting hemorrhage except by inducing contractions. 
The cervix should be dilated, forcibly if necessary, by the finger, 
water-bags, or bivalve dilators, and vertex presentations, at term 
and when engaged, delivered by forceps, but when not engaged 
by podalic version. Extraction should be followed by firm ban- 
daging of the abdomen, preceded by manual compression by a 
trained assistant. Post-partum hemorrhage is likely to occur, and 
should be prevented by full doses of ergot, either orally or hy- 
podermically. Recently, Caesarean section and hysterectomy have 
been advised for extreme conditions. 



CHAPTER II. 

POST-PARTUM HEMORRHAGE FROM UTERINE INERTIA. 

Post-partum hemorrhage, the gravest of all obstetric emergen- 
cies, is due either to defective mechanism or improper management 
of the third stage, its source being in great measure the uterine 
sinuses. 

Etiology. — Among general causes are any conditions which in- 
terfere with uterine retraction ; nervous impairment from fright, 
anxiety, or shame ; former disease like phthisis, fever, etc. ; haemo- 
philia, pelvic inflammation, metritis, uterine tumors, and ovarian 
cysts. Local causes are paralysis of uterine contractility from 
excessive use of chloroform during labor, over-distention with hy- 
dramnios and twins ; rapid delivery, especially of the placenta ; re- 
tained placenta; distended bladder and rectum. The immediate 
cause, in the large majority of cases, is precipitate extraction of 
the placenta and deficient manual compression of the uterus post 
par turn. 

Symptoms. — Blood flows from the vulva either in a continuous 
stream or enormous gush, the uterus is relaxed or inappreciable 
to the hand upon the abdomen, and signs of acute anaemia follow, 
air hunger being indicated by sighing, gasping for breath, faint 1 
ness, pallor, and blindness — a condition which once seen is never 
forgotten. Danger signals of impending flooding are a pulse over 
ioo, and previous history of a similar accident. Post-partum 
hemorrhage may occur with a well-contracted uterus, but in these 
exceptional cases is due to wounds of the cervix or other parts of 
the genital canal, the symptoms being similar in both instances. 

Treatment. — Prophylaxis. — Systematic compression of the 
uterus should be a routine as soon as the head is born in vertex 
presentations, and in those of the breech immediately after expul- 
sion of the shoulders. No attempts at extraction of the placenta 
should be made until after three good contractions have been felt 

302 



POSTPARTUM HEMORRHAGE. 



303 



by the hand upon the abdomen. Manipulation of the uterus 
should be continued for at least one-half hour after complete de- 
livery, and still longer when there are signs of inertia. Ergot 
should be given in full doses after rapid labors, after chloroform 
anaesthesia, and as a routine after operative delivery, a firm binder 
being also applied, not only for direct uterine compression but 
also to stimulate retraction. 

With Active Flooding. — Post-partum hemorrhage should be 
treated according to some plan, matured at one's leisure, so that 
in presence of the disaster every professional act is part of intelli- 
gent routine rather than haphazard experiment. 

Commence treatment by grasping the uterus externally with 
the hand (fingers in front, thumb behind), squeezing it vigorously 
to arouse contractions. These failing, 
pass the hand immediately into the uter- 
ine cavity, clearing out coagula and frag- 
ments of secundines with some roughness 
to excite contractions. Give a hypoder- 
mic of ergotole combined with strychnine, 
trinitrin, or ether, if uterine compression 
can be safely intrusted to the nurse, or 
some cool-headed visitor, while you are 
preparing and administering the hypo- 
dermic. Follow emptying of the cavity 
with an intra-uterine douche of hot deci- 
normal salt solution or plain water, at a 
temperature of i io°, or as hot as the hand 
will bear. If bleeding still persists, satu- 
rate a handful of absorbent cotton, a strip 

torn from a napkin or sheet, or even a pocket handkerchief, 
with vinegar or dilute acetic acid, thrust it into the uterus, and 
squeeze it firmly so that the fluid is expelled upon the walls. 
Should flooding continue after the use of vinegar, which is excep- 
tional, tampon the cavity with strips of sterile gauze, after the 
manner recommended by Jewett; prepare three strips of gauze 
three inches wide and ten feet long, place the woman in the dor- 
sal position, supporting the limbs by assistants, a leg bandage, or 
twisted sheet. (Twist a sheet into a rope, place its middle under 




FIG. 152.— Robb's Leg-Holder. 



304 



THE PRINCIPLES OF OBSTETRICS. 



the patient's neck, pass one-half under one shoulder, the other 
under the opposite shoulder and down across the chest, draw up 
the thighs, surround each just above the knee with the corre- 
sponding end of the sheet, and tie with half hitches.) Give first 
a vaginal douche of hot boiled water, irrigating the uterus also 
with the same. Seize each lip of the cervix with a volsellum for- 
ceps or tenaculum, and give them to an assistant. Make counter- 
pressure upon the fundus with one hand, with the other carrying 
a strip of the gauze with a long dressing forceps up to the fundus. 




Fig. 153. — Method of Application of Twisted Sheet for Leg Bandage. 



Successive strips are placed, accordion fashion, until the cavity is 
filled, leaving the free ends hanging outside the vulva. The pack, 
if aseptic, should be left in situ for twenty-four hours. 

Minor Details of Treatment. — Chemical haemostatics, like 
Monsel's solution, are objectionable, because, though bleeding is 
arrested, the resultant coagulum firmly adheres to the cavity 
walls, is likely to become septic, and there is danger of extension of 
thrombi to the uterine vessels. Iodine and turpentine are haemo- 
statics, but may provoke endometritis. . Compression of the ab- 
dominal aorta is theoretical rather than practical. Electricity is 
useful in arousing contractions, but a serviceable battery is almost 
never at hand when wanted. Putting the child to the breast and 



P03T-PARTUM HEMORRHAGE. 305 

flicking the abdomen with a wet towel are mentioned simply for 
consideration. 

Treatment of Acute Anaemia After Flooding. — The quickest re- 
storative of lost blood is large enemata of decinormal salt solution, 
the method requiring less technical skill than hypodermoclysis, 
and the large supply of heat being an especial advantage. In 
desperate cases a pint of boiled salt solution may be injected, 
secundem artem, with a large aspirating needle and fountain 
syringe into a vein of the arm, or the cellular tissue below the 
axilla, scapula, or outer surface of the thigh. Cerebral anaemia is 
relieved by taking away the pillow from under the patient's head, 
elevating the foot of the bed upon stools or chairs, and auto-trans- 
fusion. An Esmarch's bandage is applied to one arm from the 
lingers upward, and to the opposite leg beginning at the toes, al- 
lowed to remain for twenty or thirty minutes, and before removal 
the other leg and arm are bandaged in a similar manner. The 
patient should not be left for several hours, until all immediate 
danger of a second flooding is past. Convalescence is always pro- 
tracted, constitutional treatment including various chalybeates, 
forced feeding, water and other fluids to the limit of toleration, 
with reconstructives. 

Adherent Placenta. — Though some degree of retention of the 
placenta is common after labor, true pathological adhesion to the 
uterine wall is rare, being estimated to happen about once in three 
hundred and twelve pregnancies, and being generally only par- 
tial. In these anomalies of the third stage severe hemorrhage is 
likely to occur, the vessels at the placental site remaining open 
after rupture because of failure of uterine retraction. 

Diagnosis. — The placenta is not expelled by the Crede method, 
the uterus is relaxed, and flooding to a greater or less amount 
follows. 

Treatment. — Pass the hand into the uterus, using the cord as 
a guide to the situation of the placenta, find the detached margin, 
insert under it the fingers, sweeping them from side to side just 
as one would tear the uncut edges of a book. After the placenta 
is entirely separated, manipulate the uterus externally to strengthen 
contractions, allowing the hand to be expelled with the placenta in 
its grasp. Treatment for subsequent hemorrhage and anaemia is 
20 



306 THE PRINCIPLES OF OBSTETRICS. 

similar to that for ordinary post-partum flooding. In all intra- 
uterine manipulation danger of infection is lessened by the use of 
rubber gloves. 

Puerperal, or Secondary Post-Partum Hemorrhage. — The nor- 
mal course of the puerperium may be disturbed by hemorrhage 
which appears at any time after the first twenty-four hours from 
delivery. 

Etiology. — The recognized causes are stated in the order of 
frequency: retained placenta and secundines, uterine relaxation 
and displacements, detachment of coagula from the utero-placen- 
tal vessels, mental excitement, too early getting up, congestion of 
the pelvic vessels from any cause, and wounds of the birth canal. 

Treatment . — The patient should be confined to bed, a thorough 
examination made for the source of bleeding, and the cause removed 
if possible. When vaginal irrigation with very hot water does 
not check the flow, the uterus should be curetted, irrigated, and 
packed with gauze, under the most rigid antisepsis; the tampon 
being removed cautiously after twenty-four hours, and subsequent 
treatment similar to that for primary hemorrhage instituted. 

Puerperal Haematoma, or Vulvo-vaginal Thrombosis. — A rare 
form of hemorrhage associated with labor is that due to rupture 
of a varicose vein in the subcutaneous tissue of any part of the 
genital tract. 

Situation. — When rupture takes place in one or both labia 
majora, its most common situation, or, less frequently, behind or 
;at the side of the vulvo-vaginal outlet, the effusion extends down- 
ward into the perineum and to the inner surface of the thighs ; if 
it occurs in the upper part of the pelvis, it extends upward into 
any portion of the pelvic submucous tissue, the abdominal viscera, 
the anterior or posterior abdominal wall. 

Etiology. — Small thrombi are common after every labor, but 
those large enough to be of obstetric interest are very infrequent. 
Haematomata are likely to accompany dystocia from contracted 
pelvis, disproportion between passages and passenger, constitu- 
tional disease of the vascular system, or blood dyscrasia. The 
immediate cause is extraordinary straining and bearing down dur- 
ing labor, injury from unskilful use of forceps, or accidents like a 
fall, etc. 



POSTPARTUM HEMORRHAGE. 307 

Clinical History. — Though an haematoma may begin during 
labor and develop sufficiently to obstruct its progress, it ordinarily 
appears after delivery, especially of twins, or at any part of the 
puerperium. In the second stage effusion is gradual, accom- 
panied with progressive sharp, lancinating pain, normal contrac- 
tion being exaggerated by its presence. At this time its first 
symptom may be sudden collapse and other indications of con- 
cealed hemorrhage, a livid elastic tumor developing in the vagina 
or vulva. Occurring after labor, it usually forms rapidly at some 
part of the vaginal outlet, where its bulk may obstruct the lochia, 
urination, or defecation, rupture being followed by alarming or 
even fatal hemorrhage. The source is generally a vein, small or 
large, several being involved exceptionally in the accident. 

Diagnosis. — Its characteristics are sudden sharp pain during 
labor, associated either with signs of internal hemorrhage or de- 
velopment of a soft fluctuating tumor at the vaginal outlet. 
Diagnosis must be conjectural when haematoma forms within the 
abdominal or peritoneal cavity, but fortunately these varieties are 
rare. 

Prognosis. — This depends upon the size, situation, and termi- 
nation of the extravasation. Internal hemorrhage may be imme- 
diately fatal ; after spontaneous rupture or incision free bleeding 
or secondary hemorrhage is likely to follow, suppuration being com- 
mon after spontaneous rupture. Different terminations are fatal 
hemorrhage with or without rupture, suppuration and septicaemia, 
rupture with recovery or subsequent fistula, and recovery without 
rupture and with absorption of the effusion. Prognosis is favor- 
able under appropriate surgical treatment. 

Treatment. — Prophylactic: Pregnant women with varicosities 
of pelvic vessels should be carefully watched, required to keep the 
recumbent position, especially during the last weeks of gestation, 
and pelvic congestion lessened by saline cathartics. 

During Labor: Immediate delivery by forceps is demanded 
when haematomata appear during labor but are not large enough 
to obstruct it; when, however, progress is delayed, they should be 
incised at once, coagula removed, and the head extracted as 
quickly as possible. 

After Labor: If the haematoma is unruptured, absorption 



308 THE PRINCIPLES OF OBSTETRICS. 

should be encouraged by forbidding straining during urination and 
defecation, requiring absolute quiet in bed, and making pressure 
upon the tumor by rubber bags filled with ice water, which are to 
be removed often for vaginal irrigation. The ordinary gauze tam- 
pon is unsuitable, because of the impossibility of preventing infec- 
tion during its application. The tumor should not be incised while 
hemorrhage is still active, on account of the difficulty of arresting 
it and the liability of secondary bleeding. When, however, spon- 
taneous rupture threatens or there is evident suppuration, incision 
should not be delayed, the cavity being cleansed, packed with 
gauze, and pressure applied by a firm bandage. Bleeding vessels, 
after incision, should be ligated if possible; suppuration, which 
ordinarily follows rupture or incision, treated upon surgical prin- 
ciples, and convalescence hastened by the most nutritious diet, 
quinine, iron, etc. 

Fracture and Diastasis of Pelvic Articulations during Labor. 
—These accidents usually occur either from violence during for- 
ceps or version deliveries, or spontaneously from previous disease 
of adjacent bones, and are recognized at the time by hearing or 
feeling the rupture, afterward by the ordinary signs of fracture : 
pain, crepitation, with inability to sit in bed or stand upon the 
feet. Prognosis is favorable for ultimate recovery without lame- 
ness or interference with walking, but inflammation or suppura- 
tion of the joint may result, with retarded convalescence. Neu- 
ralgia of the coccyx, after its fracture in labor, is likelv to be 
persistent. 

Treatment. — Details of treatment are without the scope of 
obstetrics, being largely surgical, but cure and restoration of 
function generally follow after long confinement to bed, with use 
of fixation apparatus about the hips. 

Sudden Death During Labor. — This most deplorable accident 
of parturition is rare, resulting ordinarily from embolism, throm- 
bosis, shock, hemorrhage, cerebral apoplexy, unskilful use of 
chloroform, cardiac disease, syncope, or extraordinary nervous 
strain. The presence of any one of these emergencies should 
stimulate the obstetrician to the utmost resources of his art, in 
order to avert a fatal termination. 

Post-mortem Delivery. — The unborn child lives but a short 



POSTPARTUM HEMOBBHAGE. 309 

time after its mother's death, death of both being usually simul- 
taneous. In case of maternal death from disease or accident 
during labor the fetal heart should be carefully auscultated, and, 
if pulsating, delivery should be effected in the quickest possible 
manner, usually by accouchement force and forceps. The author 
delivered a living child, some minutes after death of the mother 
from heart paralysis, by manual dilatation of the cervix and rapid 
extraction with forceps. 






CHAPTER III. 

LACERATIONS OF THE BIRTH CANAL. 

Cervix. — Nicks or slight tears of the cervical outlet accom- 
pany almost every labor, bat are exceptionally deep enough to 
cause serious bleeding. Lacerations of the external os extend 
upward and are usually bilateral, sometimes confined to one side, 
the centre of the anterior lip, or are star-shaped. The tear is very 
rarely in a circular direction, a ring even from the vaginal portion 
being completely torn away. 

Etiology. — Under an excess of driving or extracting force the 
cervix tears rather than stretches, most lacerations ending at the 
vaginal attachment, because the latter is ordinarily fully dilated 
before the presenting part descends low enough to overstretch 
the cervix. The immediate cause is hasty delivery, stenosis of 
the external os from rigidity or cicatrices, "dry birth," extraction 
with forceps, or version before full dilatation. 

Symptoms. — Hemorrhage from the placental site does not oc- 
cur with good contractions; therefore flooding when the uterus 
is well retracted is probably from wounds of the lower segment, 
which should thoroughly be examined by finger, and, if available, 
with speculum. The characteristic of hemorrhage from cervical 
lacerations is a continuous stream of bright red (arterial) blood. 

Treatment. — The first duty is to arrest hemorrhage, which can 
generally be effected by steady uterine compression, particularly 
if at the same time the uterus is pressed well down into the pel- 
vis. Manipulation failing, it may be arrested temporarily by tam- 
poning the vaginal vault with pledgets of absorbent cotton or 
strips of any cloth, wrung out in boiled decinormal salt solution or 
bichloride (i to 5,000). The vagina can always be tamponed 
most successfully in Sims' position through his speculum, but 
trained assistance is necessary, and without it the dorsal position 
must be taken. 

310 



LACERATIONS OF THE BIRTH CANAL. 311 

Most gynaecologists advise against immediate trachelorrhaphy 
except as a last resort to check bleeding, because the majority of 
cervical lacerations heal spontaneously; sutures, though tight 
enough when first inserted, become loose after a few hours from 
rapidity of involution, and there is danger that swelling will close 
the canal, interfering thereby with drainage. 

When suturing is necessary, and a skilled assistant is available,, 
place the woman in Sims' position and expose the cervix with his. 
speculum. If working single-handed, use the dorsal or lithotomy 
position, drawing the hips well down to edge of the bed and sup- 
porting the thighs with leg bandage. Irrigate the canal with boiled 
decinormal salt solution, lysol one per cent, or bichloride i to 5,000,. 
being particularly careful to cleanse the torn edges. Draw down 
the uterus with volsellum forceps, or, if this is not at hand, have 
the assistant depress it as much as possible by suprapubic press- 
ure, placing the first suture by the sense of touch as high as pos- 
sible, when, by using this suture as tractor, the cervix can usually 
be drawn down to the vulva. Three sutures, three-fourths of an 
inch apart, are generally sufficient to close the laceration on each 
side, great care being taken not to include within them the mu- 
cous surface of the canal. Ordinarily anaesthesia during the oper- 
ation and subsequent douching are unnecessary. 

Separation of a circular ring from the cervix is not followed 
ordinarily by serious hemorrhage, nor is the normal course of the 
lying-in disturbed. 

Lacerations of Vagina, Excluding Perineum. — Wounds of the 
vaginal canal are usually caused by hasty delivery, want of elastic- 
ity (as in old primiparae), extension from the cervix, too large hand 
of the operator, and especially the edge of a forceps blade during 
extraction. 

Tears of the posterior wall may open into the deep tissues 
about the cervix, and rupture the uterine arteries, ureters, and 
sometimes the recto-vaginal septum. Hemorrhage from such 
wounds may be checked by packing with gauze, well sterilized 
strips of linen, or by closing the rent with running catgut stitch. 
Those upon the anterior wall are usually made with a forceps blade 
which does not fit tightly to the child's head, and are apt to bleed 
profusely, especially if involving the plexus of vessels about the 



312 



THE PRINCIPLES OF OBSTETRJes. 



anterior commissure. Bleeding from this location, if at all de- 
cided, should be arrested by careful suturing with catgut. 

Lacerations of the Perineum. — Frequency.— The, pelvic floor 
is lacerated during labor in from fifteen to thirty-five per cent of 
primiparae and ten per cent of multiparas. 

Varieties. — Lacerations are incomplete when restricted to the 
perineal structures without involving the sphincter ani, and com- 
plete when the)' pass through 
the rectum also, the tear being 
wholly internal, external, or both 
combined. Those of the first 
degree extend through the pos- 
terior commissure half-way to the 
anus, not including the perineal 
muscle, second degree to the 
sphincter ani, and those of the 
third into the rectum. Internal 
ruptures are always lateral to the 
rectum, in either vaginal sulcus 
or both sulci, and take any direc- 
tion, being usually straight if sin- 
gle, or Y-shaped if double. 

The etiology and prophylaxis 
have been sufficiently considered. 
Symptoms/. — Lacerations of 
the vulvar outlet and perineum 
are evident on careful inspection, 
and indicated by smarting or act- 
ual pain at this region and some 
amount of hemorrhage. After every labor the birth canal ought 
to be methodically inspected, and any injury noted. 

Treatment. — All wounds of the pelvic floor, except slight 
nicking of the posterior commissure, due to labor should be re- 
paired as soon after delivery of the placenta as is practicable. 
Immediate perineorrhaphy ma}' be deferred, when it would neces- 
sarily interfere with attentions for relief of urgent conditions of 
the mother or child (hemorrhage, shock, asphyxia, etc.), when 
the parts are severely bruised or infected, in the absence of 




Fig. 



[54. — Incomplete Rupture of the 
Perineum. 



LACEBATIOXS OF THE BIRTH CAXAL. 



313 



needful trained assistance, and under especially unfavorable en- 
vironment. 

Immediate Perineorrhaphy. — The necessary instruments and 
materials are scissors, two ordinary surgeon's curved needles (in 
case one should break), with large eye, needle-holder or two hae- 
mostats, all previously sterilized by boiling ten minutes ; a bottle 
of reliable catgut, small and medium, a carton of absorbent cot- 
ton, and fountain syringe filled with boiled decinormal salt solution, 
lysol one per cent, or bichloride I to 5,000. Place the patient in 
the dorsal or lithotomy position, the legs being supported by as- 
sistants, leg bandage, or twisted sheet. 

Cleanse the parts carefully of all blood, meconium, urine, etc., 
and cover the thighs and pubic region with clean towels. Irrigate 
the vagina with one of the solutions specified, and place a tampon 
of absorbent cotton above the upper angle of the wound to pre- 
vent passage of blood over the field of operation. Anaesthesia, by 
ether, is more humane to the patient, but not absolutely necessary. 

Lacerations of First and Second Degrees. — Trim off all ragged 
edges from the rupture. Close the 
vaginal wound first, inserting a stitch 
of small catgut above its upper an- 
gle, passing the needle at right angles 
to the cut surface and including the sev- 
eral strata of tissues down to the bottom 
of the tear, tie, and continue with the 
same catgut in a running stitch to the 
muco-cutaneous junction. Repeat on 
the opposite side, if necessary. When 
the vaginal wound is closed, insert the 
first perineal suture of medium catgut, 
one-half an inch in front of the lower 
angle of the laceration and one-half an 
inch from its edge, passing the needle 
deep enough to include the end of the 
torn muscle. Sweep the needle through 
the tissues not quite to the bottom of 
the tear and continue out through the opposite side, emerging 
as accurately as possible upon the same level as the entrance. 




Fig. 



;.— Method of Closing 
Vaginal Wound. 



314 



THE PRINCIPLES OF OBSTETRICS. 



Leave the ends of the suture long and untied. Repeat the in- 
terrupted sutures every half-inch until the vaginal sutures are 
reached. Tie from below upward, not closely enough to strangu- 
late the tissues (shown by white line under the stitch), coapting 
all skin edges perfectly. 

Complete Lacerations.— Repair is more difficult than for in- 
complete rupture, and the advantages of skilled assistance are 
obvious. 

Begin by closing the vaginal tear as already described. Then 
enter the needle, threaded with medium catgut, outside the edge 





Fig. 156. — Complete Rupture. Peri- 
neal sutures inserted, read}- for 
tying. 



Fig. 157. — Complete Rupt- 
ure. Anal sutures tied, a, 
Reinforcing stitch. 



of the torn sphincter, just posterior to the centre of its transverse 
diameter, burying it near the cut surface of the recto-vaginal sep- 
tum and emerging exactly opposite. Place a second suture one- 
half an inch outside the first in a similar manner. Insert the 
perineal sutures as described for incomplete rupture. After the 
wound is closed, reinforce the line of primary stitches with a sin- 
gle catgut suture, medium size, placed one-half an inch outside 
them and just above the closed sphincter. 

Final Technique. — Remove the vaginal tampon, irrigate the 



LACEBATIOm OF THE BIRTH CANAL. 315 

lower canal, and cleanse the external parts with solution ; apply a 
compress of sterile gauze or other linen, and over all a fresh laun- 
dered napkin, its ends being fastened to the binder. It is not 
necessary to bind the knees. The catheter, if needed, should be 
used for forty-eight hours, and especial care taken to keep the 
wound dry and sterile. If there are much pain and swelling apply 
hot compresses of lysol one per cent, or bichloride I to 5,000. 
No douching is required unless the lochia become offensive. On 
the morning of the third day after the complete operation give an 
enema of an ounce of sweet oil, and an hour afterward one of 
ordinary suds ; after that for incomplete rupture no especial direcr 
tions are needed for catharsis. The remainder of the technique 
is similar to that for normal labor. 

Repair by Granulation. — When a perineal rupture fails to 
unite after suturing, owing to lessening of vitality of the parts, 
directly from traumatism or indirectly from septic infection, relief 
from soreness, early separation of sloughs, and cicatrization are 
hastened by application to the surfaces of the wound of gauze 
packs, moistened with an antiseptic solution (lysol or bichloride), 
or better by interposing between them a folded strip of linen, satu- 
rated with a mixture of olive oil, two parts, and turpentine, one 
part. These applications should be renewed after each urination 
or defecation. In the experience of the author, cicatrization of 
the wound is delayed by bathing its immediate surface with water, 
either plain or medicated. 



CHAPTER IV. 



RUPTURE OF THE UTERUS. 

Frequency. — Rupture of the puerperal uterus is estimated to 
occur once in every four thousand labors, most often among the 
poor, who are lacking skilled obstetrical assistance,, in multipara? 
from weakening of the walls as a result of repeated pregnancies, 
with degenerations of any kind, fibroids, former operations like 
Caesarean section, and direct injury. 

Etiology. — Bandl first recognized that the most frequent cause 
is .obstructed labor, preventing the child from descending into the 
pelvis, with overstretching of the lower uterine segment. It is 

immediately due to the abuse of 
ergot, or injury from unskilful 
operation, forceps with the cer- 
vix undilated, and version in a 
contracted uterus. More gen- 
eral causes are weakness of the 
walls from former disease, and 
necrosis from pressure against 
a sharp projecting growth in the 
bony canal. 

Varieties. — Two varieties 
are distinguished : incomplete, if 
the rupture is through the ute- 
rine wall only ; and complete, if 
through the peritoneal coat also. 
Mechanism of Rupture. — 
When there is any insuperable 
obstacle to spontaneous descent 
(contracted pelvis, tumors, ex- 
cessive size of the head or posi- 
tion in which delivery, either 




Pig. 158.— Rupture of the Uterus with 
the Lip of the Os Severed. This form 
is especially dangerous because the 
infectious germs of the vagina pene- 
trate directly into the peritoneal cav- 
ity. (Schaeffer.) 



316 



RUPTURE OF THE UTERUS. 



317 




spontaneous or artificial, cannot occur), the upper uterine seg- 
ment contracts until the child is expelled from it, but descent being 
impossible further progress is arrested. The lower segment con- 
tinues to stretch under the driv- 
ing force of the contractile por- 
tion, and a distinct ridge forms 
between the active and passive 
cavities. This contraction ring 
or ring of Bandl, who first de- 
scribed it, is readily seen and felt 
across the abdomen between the 
symphysis and umbilicus, about 
on a level with the attachment 
of the peritoneum to the uterus. 
When the limit of distention of 
the thinned lower segment is 
reached, it gives way along the 
line of greatest resistance, be- 
ginning almost always in this por- 
tion and extending transversely 
upon the anterior, lateral, or pos- 
terior surface. The edges of the 
tear are irregular, swollen, and 
filled with blood, rupture being 
usually complete rather than in- 
complete. The peritoneum is at 

the same time often dissected away from the uterus, and forms 
a cavity which fills with blood (haematoma). 

After extensive rupture the intestines prolapse into the uterus 
and vagina, and the child wholly or partially escapes into the ab- 
dominal cavity, where it almost immediately dies. Subsequently 
it may putrefy and septic peritonitis follow, or become capsulated 
and change into a lithopedion. The cavity formed by peritoneum 
may be walled off by inflammation, and degenerative processes 
take place in the effusion. 

Symptoms. — After long vigorous contractions in and full dila- 
tation of an obstructed uterus, the patient feels a sudden, sharp, 
tearing pain in the region of the womb, blood flows from the 



Fig. 159.— Funnel-Shaped Complete 
Rupture of the Uterus, extend- 
ing from the Contraction Ring 
to a Thumb's Width Above the 
External Os. The latter limit 
corresponds to the posterior peri- 
toneal attachment or to the in- 
sertion of the retractores uteri 
muscles. (Schaeffer.) 



318 



THE PRINCIPLES OE OBSTETRICS. 



4 



vulva, and shock, pallor, rapid pulse, etc., indicate the occurrence 
of some severe accident. External examination finds the contrac- 
tion ring near the umbilicus, vaginal exami- 
nation demonstrates that the presenting part 
has receded or even disappeared from touch, 
and on passing the fingers or hand into the 
uterus it is found to be ruptured to a greater 
or less extent, with possibly prolapse into it 
of the intestines. Particular details of this 
description may be lacking, depending upon 
the extent of the wound. 

Diagnosis. — Rupture of the puerperal 
uterus is most often mistaken for accidental 
hemorrhage, the points of distinction be- 
tween them having been given in the sec- 
tion upon the latter. It is also mistaken for 
placenta praevia, because in uterine rupture 
the placenta is detached and appears in front 
of the child. Either of these anomalies in 
labor are differentiated by careful intra-uter- 
ine examination. Rupture is diagnosed by 
feeling the wound, the upper segment is 
firmly contracted into a small ball, and a 
portion or the whole of the child's body may 
be felt within the abdominal cavity. On the 
contrary, few if any of its diagnostic symp- 
toms may be present, and yet a considerable 
perforation have occurred, which is indicated 
only by the presence of severe peritonitis 
following soon after delivery. 

Prognosis. — This depends upon the lo- 
cation, the size of the tear, and the method 
of treatment, particularly upon the amount 
of contamination of the peritoneal cavity by 
liquor amnii, blood, meconium, and whether 
the child has passed into it. Under modern 
surgical treatment, maternal mortality, which was formerly ninety 
per cent, has been reduced to about fifty per cent, death occurring 



RUPTURE OF THE UTERUS. 319 

usually within twenty-four hours, and the majority within three 
days, from sepsis, hemorrhage, and shock. Secondary rupture is 
liable to occur in each succeeding labor. Fetal mortality is over 
ninety per cent, from arrest of circulation. 

Treatment. — It is more important for the general practitioner 
to know how to prevent rupture of the uterus than to manage it 
afterward. The danger signals are progressive distention of the 
lower uterine segment and ascent of the contraction ring in any 
obstructed labor from deformed pelvis, malformations and ob- 
liquities of the uterus, malpresentations, etc. Threatened rupture 
should be prevented by immediate delivery, according to that 
method which is likely to do the least damage to passage or pas- 
senger. 

General Directions for Delivery in Ruptured Uterus. — If the 
rupture is small and the greater part of the child within the uterus, 
extraction should be by forceps, podalic version, or preferably 
by craniotomy as least likely to increase the extent of the tear. 
Even if the placenta has passed into the abdominal cavity, it 
should be withdrawn ordinarily by way of the vagina, since the 
uterus will not expel it. Traction upon the cord will bring it 
within reach of the hand in the uterus ; bat if there is great diffi- 
culty in so doing, it should be left for delivery by laparotomy. 

Special Directions for Particular Forms of Rupture. — Incom- 
plete. — First irrigate the uterine cavity to remove all coagula, 
liquor amnii, fragments of secundines, etc.; then pack with sterile 
gauze to control hemorrhage and provide for drainage. Capillary 
drainage of the cervix, and in some cases of the uterine cavity, 
offers a favorable chance for recovery. The edges of the tear 
must be closed as much as possible by the fingers or by pressure 
from the outside through the abdominal wall. A strip of gauze 
is then inserted as far as possible into the uterus without reaching 
the wound. 

Complete, but small tear, low down upon the posterior wall, 
and when little foreign matter has escaped into the peritoneal cav- 
ity, treatment is similar to that for incomplete rupture. 

Complete, but tear extensive, large quantities of fluids dis- 
charged into the abdominal cavity, laparotomy is imperative, with 
some form of hysterectomy. 



320 THE PRINCIPLES OF OBSTETRICS. 



INVERSION OF THE PUERPERAL UTERUS. 

This anomaly of parturition is a veritable obstetric curiosity, 
its estimated frequency being about once in one hundred and fifty 
thousand labors. The degree of inversion, from the slightest 
cupping of the top of the fundus to entire reversal of surfaces, 
determines whether it is partial or complete. 

Etiology. — It may occur spontaneously, but in the great ma- 
jority of cases results from dragging an adherent placenta away 
from a relaxed uterus, a somewhat doubtful cause being traction 
upon a normal placenta by a short cord and improper application 
of the Crede method. Whatever the explanation, the accident 
cannot occur with a well-contracted uterus. 

Diagnosis. — Inversion takes place either just before or after 
extraction of the placenta, accompanied with severe pain, hemor- 
rhage, and sudden shock, which are the usual indications of puer- 
peral accident. If partial only, external examination shows the 
top of the fundus cup-shaped, the cavity deepening according to 
the amount of reversal of the external and internal surfaces. 
When complete, abdominal palpation recognizes the cervical ring, 
and disappearance of the uterine bod}-, which is found as a tumor 
in the vagina well down to the outlet. Complete inversion is 
usually mistaken for the head of a second child or a pedunculated 
fibroid, from which it is differentiated by the characteristic pulpy 
feeling of the endometrium, possibly -appearance of the tubal 
orifices, and by passing a sound between the cervix and uterine 
wall. 

Prognosis. — Two-thirds of the patients die within a few hours 
after inversion from shock and hemorrhage, or later from metritis 
and gangrene, and hemorrhage at any time during the puerperium. 
Exceptionally the accident is not immediately fatal, involution takes 
place, and chronic inversion follows. 

Treatment. — Whatever the physical condition of the woman, 
the uterus must be replaced at once while still relaxed, correction 
being impossible after contraction unless by difficult operation. 
If the placenta is still adherent but separable, remove it before 
attempting reposition ; if not, replace both together. The read- 



EUPTUEE OF THE UTERUS. 321 

iest method of replacement is to push the fundus upward and for- 
ward, so as to clear the promontory of the sacrum, with the closed 
hand, or after grasping the tumor with the hand, so that it may 
be lessened in size as much as possible, push upward in the same 
manner, using counter-pressure at the same time upon the abdo- 
men. 

Difficult Cases.— If replacement is very difficult or impossible 
immediately after inversion, it is better to summon expert gynae- 
cological assistance rather than to prolong attempts, which are 
almost sure to cause further shock, hemorrhage, and liability of 
septic infection. 
21 



PART IX. 

PATHOLOGY OF THE PUER- 
PERIUM. 



CHAPTER I. 
PUERPERAL FEVER. 

The terms puerperal fever, puerperal septicaemia, child-bed 
fever, and metria are synonyms of a pathological condition occur- 
ring during the puerperium, and identical with ordinary surgical 
fever. 

History.- — From primeval times an idea has existed among 
civilized and barbarian people, that women in childbirth needed 
protection from contamination by disease. Such a principle has 
been noticed among the American Indians, for instance, illus- 
trated in the custom of their women of sitting over a smouldering 
fire after delivery, or taking the sweat bath. This function is 
surrounded among aboriginal people by all manner of supersti- 
tious rites, and early medical literature abounds in directions for 
the care of childbirth, largely useless and absurd, with an occa- 
sional fact of scientific value. 

At the beginning of the last century a few shrewd observers 
announced their belief, that the fever so often present during the 
lying-in was in some inexplicable manner produced by causes ex- 
ternal to the patient and infectious in character. Professional 
attention was first publicly called to the subject in America in 
1843, by Dr. Oliver Wendell Holmes, then professor of anatomy 
in the Harvard Medical School, in a thesis which demonstrated, 
by inductive reasoning and clinical histories, that child-bed fever 
was contagious. This was followed in 1846 by the discoveries of 
Semmelweiss, in the Maternity Department of the General Hos- 
pital at Vienna, who independently confirmed the correctness of 
the principle. Since that date Lister, Pasteur, Simpson, and 
many others have proven the infectious nature of pathogenic 
micro-organisms in the genital tact of the parturient woman. 
L T pon this foundation of scientific thought and clinical experience 
has developed the recent method of protective delivery in child- 

325 



326 THE PRINCIPLES OF OBSTETRICS. 

birth, to which countless women owe their lives and that of their 
children. 

Frequency. — Under the modern method of conducting labor 
maternal mortality from sepsis is practically nothing, but under 
the older methods, still largely used by physicians, it is certainly 
one per cent, and often much higher. Many women who survive 
the immediate dangers of infection in childbirth remain invalids 
to greater or less extent from its sequelae. Hart in a recent 
paper says : " Many scientific workers have shown that puerperal 
septicaemia is heterogenetic and preventable by antisepsis and 
aseptic measures. Despite these clearly ascertained facts, which 
should lead to a perfectly definite and successful prophylaxis, the 
deaths from puerperal septicaemia have not diminished in this 
country (England), but in some years have notably increased." 

Etiology. — The following is a practical summary of our nres- 
ent knowledge regarding the etiology of puerperal fever. The 
vagina exceptionally contains before labor pathogenic organisms. 
Becoming infected immediately afterward, protection is afforded 
by its natural germicidal power and a special bacillus. During 
and after labor, it is immunized mechanically by discharge of 
liquor amnii, passage through the canal of the body of the child, 
descent of the placenta with its membranes, and lochia. If septic 
germs are already present, they are probably weakened in viru- 
lence. 

Bacteriology. — The variety of organisms most frequently found 
in the birth canal is the streptococcus, much less commonly the 
staphylococcus, bacillus coli communis, gonococcus, bacillus of 
diphtheria and typhoid, and virus of scarlatina and tetanus, several 
of these being often present at the same time. Toxins and pto- 
mains resulting from decomposition of animal substances (pla- 
cental and decidual debris, broken-down coagula, and lochia) are 
also discoverable. 

Sources of Infection. — These are almost entirely heterogenetic 
(derived from other sources than the patient), in the majority of 
cases the hands of the physician, which have become contami- 
nated with discharges from suppurating wounds, from patients 
with scarlatina, erysipelas, diphtheria, or while making an autopsy. 
Occasionally infection can be traced to nurses and visitors, obstet- 



PUERPERAL FEVER. 327 

rical instruments and dressings used during and after labor 
(forceps, catheters, syringes, napkins, etc.), water used in cleans- 
ing and douching, body linen and bed clothing, and probably foul 
atmosphere Decomposed blood clots, fragments of placenta and 
secundines are also carriers of sepsis. 

The source is autogenetic (derived from the patient herself), 
in a fractional proportion of cases, when traceable to a former sal- 
pingitis, fibroids and dermoid tumor that have been bruised or 
torn during labor, and exceptionally to a previous endometritis. 

Channels of Infection. — Puerperal infection is carried mainly 
by the lymphatics, less so by veins, always beginning as a local 
process, and extending secondarily to the general system. The 
points of entrance are wounds of the vagina, particularly those 
about the perineum and vulva, lacerations of the cervix, and pos- 
sibly intact mucous membrane. Infection at the lower portion of 
the canal is commonly superficial, having the characteristics of a 
simple abscess, but becomes more and more systemic as it ex- 
tends upward because the higher the entrance point of septic 
organisms the less the resistant power of the mucous membrane. 
Results of Infection. — Puerperal infection results in vaginitis, 
superficial, ulcerative, or pseudo-diphtheritic; endocervicitis and 
metritis; by extension through the uterine walls and Fallopian 
tubes in parametritis and perimetritis, salpingitis and pyosalpinx, 
and ovaritis. Peritonitis, either pelvic or diffuse, is often associated 
with these. If the genito-urinary tract is invaded cystitis may 
follow, with ureteritis and pyelitis. Sapraemia and pyaemia are 
due to absorption of toxins and ptomains, may cause metastatic 
abscess in any part of the body, and inflammation of any of the 
thoracic and abdominal viscera. 

Diagnosis and Symptoms. — The symptoms of puerperal fever 
are general and local. General: The temperature begins to rise 
upon the second or third day, occasionally is deferred to the fourth 
or fifth, but is then exceptional, owing to the fact that at this time 
wounds are granulating and infection is thereby prevented. The 
pulse is rapid, from ioo to 140, there are furred tongue, languor, 
loss of appetite, sometimes great thirst, nausea with vomiting, and 
more or less decided chill. Local symptoms are offensive lochia, 
various forms of inflammation about the vagina, possibly local 



328 THE PRINCIPLES OF OBSTETRICS. 

peritonitis. As the degree of infection increases, prostration 
deepens, diarrhoea, delirium, and other signs of severe blood poi- 
soning follow. The most important danger signals are rise in 
pulse rate and temperature ; of themselves significant of infection. 
The diagnosis of non-infective fever should be made by exclusion ; 
malaria by quinine and microscopic examination for plasmodia 
malariae; mammitis, pneumonia, typhoid, fecal retention, etc., by 
appropriate signs and examination. Bacterial examination of uter- 
ine secretions is not reliable, and its findings may be fallacious. 

Prophylaxis. — The chapter on the conduct of normal labor 
indicates that prevention of septic infection during labor and the 
puerperium depends upon thorough asepsis of the physician, 
patient, nurse, and all materials used in it. It is unnecessary 
here to repeat the technique, but its two essentials are personal 
sterilization of the operator and infrequent vaginal examinations. 
Infection is possible under the most exact technique, but experi- 
ence demonstrates that sterile hands and few vaginal examinations 
lessen its probability. The fact remains, that the mortality and 
morbidity of childbirth in private practice are still nearly or quite 
as great as during pre-antiseptic times, owing to refusal or indif- 
ference of the family physician to adopt the protective method of 
delivery. In the eloquent words of Holmes, "God forbid that 
any member of the profession to which she trusts her life, doubly 
precious at that eventful period, should hazard it negligently, un- 
advisably, or selfishly." 

Treatment. — Local. — Treatment should begin with disinfec- 
tion of the entire birth canal in the following manner : The opera- 
tor sterilizes his hands and arms as carefully as for an abdominal 
section, by prolonged washing with green soap and hot water, 
finishing by immersion in bichloride I to 2,000, or permanganate 
of potash and oxalic acid. After attendance upon patients ill with 
any infectious disease, the use of rubber gloves, boiled in a napkin 
for ten minutes, is especially recommended. 

The patient should be placed in the dorsal or lithotomy posi- 
tion, the legs being supported in the usual manner, and the exter- 
nal genitals and vagina disinfected with green soap and bichloride 
solution 1 to 5,000. Draw down the uterus with a volsellum and 
irrigate the cavity with bichloride solution 1 to 5,000, from a 



PUERPERAL FEVER. 329 

fountain syringe. Then, using a large dull curette, scrape the 
interior until nothing returns but bright blood, and follow with a 
second irrigation of bichloride and plain water, or preferably, in- 
stead of the mercurial, decinormal salt solution, thoroughly boiled. 
If the uterus is soft and flabby or the lochia appear to be retarded 
by its flexion, a strip of gauze may be inserted through the inner 
os for drainage. Any ulcers or diphtheritic spots in the vagina 
or about the outlet should be touched with ninety-five-per-cent 
carbolic acid or a solution of nitrate of silver one drachm to the 
ounce. 

Under favorable conditions the temperature falls after curet- 
tage and irrigation, but should it again rise, the latter with decinor- 
mal salt solution is to be repeated every four or six hours, p. r. n. 

Constitutional Treatment. — On the first appearance of a rise 
of temperature give triturates of calomel one-tenth of a grain, and 
sodium one grain, one every quarter of an hour until fifteen are 
taken, followed by seidlitz powders or saturated solution of Epsom 
salts, until free catharsis results, which usually relieves the severity 
of pain. Nourishment should be milk, either plain or predigested, 
as much as possible of alcohol in some form to its full physiologi- 
cal limit, with strychnine, trinitrin, digitalis, quinine and iron, in 
combination. Opiates are to be used for emergencies only. Deci- 
normal salt solution, preferably in the form of enemata, is of the 
utmost service. Serum therapy is as yet unreliable. The ques- 
tion of operative treatment by laparotomy should be left to the de- 
cision of a reliable abdominal surgeon. 

SPECIAL LESIONS OF PUERPERAL SEPSIS. 

Septic inflammation of the puerperal tract is characterized by 
structural peculiarities, situation, and intensity of infection. The 
lesions are found in any portion of the mucous membrane or its 
subdivisions, from the entrance of the vagina to outlet of the 
tubes, and in adjacent organs and structures (ovaries, peritoneum, 
intestines, genito-urinary system, lymphatics, and blood-vessels). 
Puerperal infection may cause also, either primarily or secondarily 
by extension, inflammation of remote portions of the body, lungs, 
heart, kidneys, etc. 

Septic Vaginitis, Endometritis, and Salpingitis. — Puerperal 



330 THE PRINCIPLES OF OBSTETRICS. 

inflammation due to septic infection of the vaginal and uterine 
mucous membrane is generally local and not especially dangerous, 
salpingitis from similar causes being more important owing to the 
liability of extension to the peritoneum. Diphtheritic inflamma- 
tion of these parts is rare and hazardous. The exudate may be 
localized in the vagina in the shape of ulcers or line the entire 
uterine cavity, oedema of the vulva being usually associated with 
it when in the vagina. The Klebs-Loeffler bacillus is exception- 
ally found at the same time with true diphtheritic membrane in 
the throat. 

Symptoms. — Vaginitis is recognized by its ordinary local symp- 
toms : heat, redness, pain, swelling of tissues, diminished, then in- 
creased, secretion, local abscess, etc., diphtheritic by exudate and 
the microscope. The most common situation for this form of 
infection is the endometrium, signs of endometritis being a soft 
uterus sensitive to pressure, retarded involution, cervix more patu- 
lous than normal, offensive lochia, and continuance of discharge of 
bright blood from the uterus. Salpingitis is recognized by pain, 
lateral or bilateral, on abdominal examination, and sensitive tumor 
on the side of the uterus. 

Treatment. — Any of these superficial inflammations should be 
treated by prolonged douching with plain hot water, or decinormal 
salt solution, and localized ulceration by carbolic acid or nitrate 
of silver. 

Metritis. — The deeper layer of the uterus may become infected 
by extension through the lymphatics from a previous endometritis, 
inflammation resulting either in sloughing of the muscles or small 
localized abscesses, which may perforate into the pelvic perito- 
neum and become encysted. 

Diagnosis is made with difficulty and with certainty only by 
abdominal section, the uterus being tender, soft, and enlarged 
upon bimanual examination. Prognosis is unfavorable. 

Treatment. — The best treatment of all forms of uterine inflam- 
mation due to puerperal infection is by thorough curettage, intra- 
uterine irrigation with decinormal salt solution, and frequent large 
vaginal douches. Appropriate general medication should be asso- 
ciated, and subsequent gynaecological management as indicated. 

Peritonitis, Pelvic and Diffuse.— Either results generally by 



PUERPERAL FEVER. 331 

extension from the uterus and tubes, less commonly from uterine 
abscess, suppuration of pelvic tumor, fibroid or dermoid, and lym- 
phangitis caused by suppuration of any pelvic structure. 

Pelvic Peritonitis, or Cellulitis.— Symptoms, Diagnosis, and 
Course. — Vaginal examination shows pain and tenderness with 
exudate in one or both broad ligaments or Douglas' cul-de-sac, the 
uterus is fixed in a hard, plaster-like effusion, the lochia are scanty, 
tympanites and nausea are generally moderate. Abscess results 
quite frequently, is detected by fluctuation at the most dependent 
point, and may become encysted or break through into the gen- 
eral peritoneal cavity. Resolution takes place with absorption of 
the inflammatory mass, and recovery follows, or the purulent col- 
lection may be discharged through the bladder, umbilicus, intes- 
tine, or more commonly the vagina. 

Treatment. — If abscess has formed, as shown by remittent 
fever, chills, sweating, etc., the most dependent or softest portion 
should be aspirated behind the uterus. If pus is found, a small in- 
cision should be made by a bistoury into which the points of a pair 
of closed scissors should be passed, opened widely, and the cavity 
carefully washed by irrigation with decinormal salt solution, any 
pockets of pus being evacuated with the finger, and great care 
taken not to break through the cyst wall. A plain gauze drain 
should be inserted to the bottom of the cavity, and removed daily, 
resolution being promoted by daily irrigation and other suitable 
treatment. 

Diffuse Peritonitis. — Symptoms and Diagnosis. — The onset is 
generally sudden, within a few days or even hours after infection, 
which is by way of the lymphatics, and course rapid. The classi- 
cal signs of general peritonitis are present : extreme tympanites, 
rapid pulse, high temperature, sunken face, severe pain, and possi- 
bly local fluctuation. Any of these signs may be slight or absent, 
and yet the most virulent type of disease exist. It is almost al- 
ways fatal within a week. 

Treatment. — This is eliminative and supportive : free catharsis, 
which usually relieves the severity of pain, large vaginal irriga- 
tions, turpentine stupes for the tympanites, ice pack or cold coil. 
Favorable results have attended the use of the Crede ointment 
of nitrate of silver (fifteen per cent of metallic silver is incorpor- 



332 THE PRINCIPLES OF OBSTETRICS. 

ated with lard by the same method as that used in prepara- 
tion of mercurial ointment, ten per cent of wax added, and the 
mass flavored with benzoated ether. From twenty to thirty min- 
utes is required for inunction). If symptoms continue after forty- 
eight hours probably pus has formed, and the only treatment is 
by an abdominal section, in which pus cavities are emptied and 
the general peritoneal cavity is irrigated with decinormal salt solu- 
tion. The disease is ordinarily fatal under any form of treatment. 

Phlegmasia Alba Dolens. Milk Leg. — Two varieties are rec- 
ognized : ( i ) Thrombotic phlegmasia, which may be (a) primary, 
from pressure upon the pelvic vessels during pregnancy, extension 
of thrombi from uterine sinuses, and retardation of blood current, 
and (b) secondary, from infection of the wall of a vessel with sub- 
sequent thrombosis; and (2) cellulitic phlegmasia, from parame- 
tritis or perimetritis, extending from the perineum or deep pelvic 
fascia to the connective tissue of the thigh and pelvis, this form 
being quite common. 

Frequency and Etiology. — The disease is exceptional in private 
practice. Almost every case is infectious in origin, and due to 
septic inflammation of the walls of the vessels, beginning at the 
placental site and extending either to the femoral vein and down 
the leg, or upward by the spermatic vein to the vena cava. Even 
if primarily due to simple thrombosis, it soon becomes infected. 

Symptoms. — After a period of invasion from the tenth to thir- 
tieth day after labor, inflammation appears, in the thrombotic 
form, at the ankle and extends upward to the groin, attended by 
pain along the course of the vessel, stiffness particularly of the 
calf of the leg, and swelling, which, in the cellulitic form, begins 
at the groin and passes downward. The leg is swollen, hard, 
white, and the veins, indicated by red streaks under the skin, are 
cordy and nodular, some degree of fever being present, with an- 
orexia, furred tongue, nausea, and vomiting. After acute symp- 
toms for about two weeks resolution occurs, or abscess may de- 
velop with gangrene. The left leg is more often affected than 
the right, but both may be inflamed at the same time. 

Prognosis. — Thrombotic phlegmasia is generally of less gravity 
than cellulitic. Chronic congestion and stiffness of the leg from 
obstruction of collateral circulation usually persist for some time, 



PUERPERAL FEVER. 333 

exceptionally gangrene takes place from lack of sufficient supply ; 
abscess in and around the vessels, metastasis from invasion by an 
infected clot of other parts of the body, embolism and sudden 
death from detachment of a thrombus being probable even in mild 
cases. 

Treatment. — Absolute quiet upon the back to prevent detach- 
ment of the clot, elevation of the leg to assist return circulation, 
and encouragement of absorption by wrapping the leg in cotton 
and oiled silk. Two or three weeks after disappearance of the 
swelling and all acute symptoms, careful massage may be used to 
relieve the oedema, and active movement cautiously attempted, 
the leg being supported by rubber stocking, and danger of em- 
bolism recognized. Abscess should be opened upon general 
surgical principles with subsequent drainage, and local treatment 
combined with strong supportive diet and medicines. 

Sapraemia, Septicaemia, and Pyaemia. — One of the most com- 
mon forms of puerperal fever is caused by absorption of toxins 
and ptomains from decomposition of dead animal matters re- 
maining in the uterus. 

Symptoms. — The more superficial septicaemia and sapraemia 
appear within the first three days, with rise of temperature and 
quickened pulse, with enlargement of the uterus and foul lochia, 
and should be suspected, even if local signs are absent, when evi- 
dent sepsis is present. Pyaemia is indicated by characteristic 
signs of general purulent infection, abscesses in various parts of 
the body, chills, fever, etc. 

Treatment. — The milder forms should be treated by disinfec- 
tion of the entire canal, curettage, and irrigation as previously 
directed, and pyaemia by ordinary surgical methods. 

Cystitis, Ureteritis, and Pyelitis. — Inflammation of the genito- 
urinary system from puerperal infection may be local, suppurative, 
or diphtheritic. The initial symptoms are those of ordinary cys- 
titis: frequent and painful urination, muco-purulent urine, pain 
over the bladder, and moderate fever. These may disappear 
under appropriate treatment, or after a few days inflammation ex- 
tend up the ureters to the kidney, general infection being indi- 
cated by passage of urine loaded with pus and micro-organisms, 
and sensitiveness over the course of the ureters and kidneys 



334 THE PRINCIPLES OF OBSTETRICS. 

Prognosis is unfavorable when the kidneys are infected and 
abscess has formed. 

Treatment. — Upon the appearance of septic cystitis the blad- 
der should immediately be irrigated with mild boric-acid or deci- 
normal salt solution, every three or four hours, salol administered 
in five-grain doses every three hours or urotropin twice daily, al- 
kaline waters freely drunk, and catharsis effected with salines. 
Puerperal pyelitis is treated essentially in a manner similar to 
that for the general disease. 

Septic pneumonia during the puerperium, pleurisy, pericarditis, 
nephritis, metastatic abscesses, and other constitutional pathologi- 
cal conditions are to be managed according to general rules. 



CHAPTER II. 

PUERPERAL CONVULSIONS. 

Puerperal convulsions are due to a variety of pathological 
conditions : eclampsia, hysteria, organic disease of the brain (apo- 
plexy, inflammation, anaemia, etc.), acute anaemia following hem- 
orrhage, and that peculiar excitability of the nervous system 
dependent upon gestation. In the obstetric sense the term is 
synonymous with puerperal eclampsia. 

ECLAMPSIA. 

A disease of gestation preceding, accompanying, or following 
labor, indicated clinically by epileptiform convulsions and uncon- 
sciousness, with usually associated albuminuria. 

Frequency. — It is estimated to occur about once in three hun- 
dred labors, three times more often among primiparae than mul- 
tiparas, is often a characteristic of illegitimate gestation, and ten 
times more frequent with multiple than single pregnancies. 
Labor is the most common time for the attack, next, before it, 
and least during the puerperium. 

Etiology. — Many theories have been suggested for its explan- 
ation, none of which seems to satisfy all requirements. Originating 
probably from many combined sources, elimination of poisonous 
materials is arrested, largely excrementitious waste from both 
mother and child, which should have been discharged by the 
emunctories, particularly the kidneys. Renal insufficiency is due 
to the kidney of pregnancy, acute or chronic nephritis, intra-ab- 
dominal pressure, or direct pressure upon the ureters. As a con- 
sequence toxaemia follows, inducing either spasm of the arterioles, 
or sudden embolism or thrombosis, with secondary anaemia of the 
brain, and convulsions as an immediate effect. Clinically the 
kidney may be anatomically healthy but insufficient, or grossly 

335 



336 THE PRINCIPLES OF OBSTETRICS. 

diseased, though still competent, and acute nephritis may be asso- 
ciated with chronic. 

Premonitory Symptoms. — Danger signals of eclampsia are a 
sudden or progressive decrease in daily amount of urine, oedema, 
especially of the face ; frontal, rarely occipital, headache ; disturb- 
ance of vision and muscae volitantes ; albuminuria with renal casts, 
progressive reduction of urea and other solids, or pain in the epi- 
gastrium. 

The Attack.— Immediate forerunners of eclampsia are severe 
frontal headache, restlessness or stupor, failure of sight, and epi- 
gastric pain, the latter being of the highest significance. The 
convulsion is typically epileptiform, the following being its usual 
characteristics : sudden arrest of sensation and motion, fixed stare, 
contracted pupils, spasm of facial muscles, the mouth and head 
being twisted to one or the other side, with tonic flexure of the 
arms and hands, the lower extremities being rarely affected. The 
tongue is often caught between the teeth and severely bitten, blood 
mingling with frothy saliva and being expelled during attempts at 
respiration. During the height of the fit, spasm of the respiratory 
muscles causes asphyxia, which changes to stertorous breathing 
as the convulsion passes off, coma deepening with each attack 
from increase of cerebral congestion. The pulse quickens, often 
becoming 140, and temperature varies from subnormal to hyper- 
pyrexia, 105 ° or more. Each convulsion lasts about one minute, 
with intervals of from a few minutes to several hours. 

Differential Diagnosis. — Eclampsia is distinguished from con- 
vulsions due to hysteria, anaemia, brain disease, and post-partum 
hemorrhage, by urinalysis and previous clinical history. 

Prognosis. — The earlier in gestation convulsions appear the 
graver the prognosis, which also is influenced by the frequency and 
number of attacks. Deep coma, suppression of urine, and paraly- 
sis are particularly unfavorable symptoms. A previous nephritis 
during a first pregnancy is very fatal, and ascending renal insuffi- 
ciency in old primiparae is almost surely so if allowed to continue. 
Death rate of the mother is highest when convulsions occur dur- 
ing pregnancy and least during the lying-in, general mortality 
being from twenty-five to thirty-five per cent, divided into thirty- 
nine per cent during labor, twenty-nine per cent ante partum,. 



PUERPERAL CONVULSIONS. 337 

and ten per cent post partum. Its immediate cause is oedema 
of brain, lungs, or larynx, asphyxia, cardiac paralysis, exhaustion, 
apoplexy, or extreme toxaemia. Fetal mortality is from fifty to 
seventy per cent, largely from asphyxiation, a certain proportion 
dying after birth from convulsions or uraemia. 

Prophylaxis. — The urine of all primiparae should be systemati- 
cally analyzed every week after the seventh month, and earlier if 
there is the slightest indication of renal failure (headache, swell- 
ing of the feet, or scanty urine). The entire amount for twenty- 
four hours should be tested for albumin with heat and nitric acid, 
and a quantitative analysis made for urea, either by taking the 
specific gravity of the gross amount in twenty-four hours or by 
the Doremus or Squibb' s ureometer. At term the specific grav- 
ity is usually steady at ioio, but a daily reduction is more signifi- 
cant than a similar increase in albumin. A less amount than 
thirty-two ounces in any twenty-four hours indicates the necessity 
for a qualitative and quantitative urinalysis. 

Prophylactic Treatment. — The prophylactic treatment for albu- 
minuria has been given in Part I., Chapter XII. 

Therapeutic Treatment of Eclampsia. — Before Viability. — In- 
stead of confusing the reader with details of the numberless plans 
of medical treatment, the following is suggested : Guard the pa- 
tient against injuring herself during the spasms Upon the first 
symptoms of an attack administer chloroform, not ether, suffi- 
ciently to control the convulsion, loosen all constricting bands 
about the neck and waist, and insert the handle of a spoon be- 
tween the teeth to prevent biting the tongue. As soon as it is 
practicable stimulate the skin and intestines to activity, in order 
to relieve the system as quickly as possible from the poison. 
Place a drop of croton oil upon the back of the tongue, and if she 
can swallow, give dessertspoonfuls of a saturated solution of Epsom 
salts every fifteen minutes until free catharsis follows. Promote 
diaphoresis by hot packs, or dry heat in this manner : Insert the 
chimney of a lighted kerosene lamp into the lower end of a piece 
of ordinary tin gutter-pipe, provided with an elbow, and place the 
other end of the pipe so that the heat will be received under the 
bedclothes ; a simple but most efficient means for causing diapho- 
resis. Inject a pint of decinormal salt solution under each breast 
22 



338 THE PRINCIPLES OF OBSTETRICS. 

or in the subaxillary line, or give large enemata of the same, the lat- 
ter being of itself perhaps the most valuable single measure. If 
the woman is plethoric, venesection from the arm to the amount 
of from twelve to sixteen ounces is undoubtedly of great advan- 
tage. In place of venesection, many American practitioners, 
especially in the South and West, rely upon the hypodermic use 
of fifteen minims of fluid extract of veratrum viride, repeating in 
five- or ten-minim doses every half-hour until the pulse is lowered 
to 60, it having been demonstrated that convulsions are impossible 
if the pulse can be kept at that rate. While under the influence 
of veratrum the recumbent position must be absolutely maintained, 
and collapse treated by hypodermics of morphine and whiskey. If 
convulsions continue, an enema of chloral gr. xxx., and bromide 
of potassium gr. lx., may be given. Certain cases apparently are 
benefited by a hypodermic of from gr. y 2 to gr. iss. of morphine, 
administered at the beginning of the attack, and repeated in gr. )i 
doses with every convulsion, until respirations are reduced to 
twelve in the minute. 

Obstetrical Treatment. — 1. Eclampsia Before Viability. — Ener- 
getic therapeutic measures should be used to arrest the attack 
and relieve toxaemia, when possibly gestation may continue to a 
successful termination. If, however, such means are unavailing, 
with sluggish or inactive kidneys and short intervals between each 
convulsion, the uterus should be emptied at once. The principal 
reason for delaying operation is consideration for the life of the 
child, but as even the first convulsion is likely to cause fatal as- 
phyxiation, a danger progressively increasing with each attack, its 
interests must give way to those of the mother. 

2. Eclampsia After Viability and During Labor. — The ques- 
tion of immediate delivery during convulsions, after viability, is 
still unsettled, each side of the argument having enthusiastic ad- 
vocates. While every case must be managed according to indi- 
vidual characteristics, the following conservative method has 
received the endorsement of the best American authorities. As 
labor is initiated ordinarily with the first convulsions, which cease 
in eighty per cent of cases after the uterus is empty, it would 
seem to be a natural inference that labor should be hastened, pro- 
vided the method of operation does not aggravate the already 



PVEBPEBAL CONVULSIONS. 339 

extreme degree of nervous tension. Therefore, while waiting for 
spontaneous dilatation, chloroform can be used to check the im- 
mediate attack and elimination stimulated by appropriate thera- 
peutic measures. As soon as the cervix opens to the size of a 
silver dollar, expulsion should be assisted by forceps or podalic 
version. Certainly, when therapeusis evidently fails, there would 
seem to be no valid reason why the uterus should not be emptied 
as quickly as the integrity of the outlet will permit. 

3. Eclampsia After Delivery. — The therapeutic management 
of eclampsia occurring during the puerperium is not essentially 
different from that during labor. 



CHAPTER III. 

DISEASES OF BREASTS DURING THE 
PUERPERIUM. 

Non-inflammatory affections of the breasts during lactation 
are discussed in Part III., Chapter IV., Nursing and Artificial 
Feeding. 

MASTITIS. 

Puerperal inflammation of the breast appears two or three 
weeks after labor, ordinarily involving a single mamma, sometimes 
extending to the other, and exceptionally occurring in both simul- 
taneously It is more likely to occur in blondes than brunettes, 
and in first rather than succeeding pregnancies. 

Varieties — Three varieties are differentiated: Subcutaneous, 
a superficial inflammation of tissues belonging to the areola ; par- 
enchymatous or glandular, affecting the true gland ; and subgland- 
ular, the connective tissues upon which the breast lies, each vari- 
ety being often combined with the others. 

Etiology. — The essential cause for all forms is sepsis, which 
in the subcutaneous variety enters through the Montgomery folli- 
cles ; in the glandular, through fissures and other lesions of the 
nipple, lactiferous ducts, or occasionally by metastasis from a pus 
collection in a distant organ ; and in the subglandular, by exten- 
sion from the overlying gland or lymphatics. The immediate 
source of infection is general uncleanliness, dirty clothing, decom- 
posing lochia carried to the breast by the fingers of the mother or 
nurse, pus from a septic umbilicus, sour milk which has been 
allowed to collect upon the nipple, or stomatitis from the mouth 
of the child. Predisposing causes are reduced vitality of the 
mother due to the strain of labor and pregnancy, engorgement of 
the lobules (caked breast), and traumatism from violence or too 
energetic nursing. 

Symptoms and Diagnosis. — The subcutaneous variety resem- 

340 



DISEASES OF BREASTS. 341 

bles a simple abscess or boil, one sometimes following another by 
repeated auto-infection, without constitutional symptoms 

Glandular mastitis is more severe in character, depending upon 
whether inflammation is confined to a single lobule or affects sev- 
eral lobules at the same time. It usually begins in a part whicn 
has been previously congested, with lancinating pain, increased 
tension, heat, redness, and induration of the skin, accompanied 
with chills, increased pulse and temperature, and usual signs of 
fever. In favorable cases resolution follows without suppuration, 
the latter being indicated by pointing of the swelling, fluctuation, 
and brawny, dusky oedema of the surface. The collection may 
discharge spontaneously after a few days, leaving persistent sinuses 
from which flows a sanious, milky fluid, with gradual healing of 
the cavity, or inflammation extend to neighboring lobules, the 
process continuing indefinitely until the entire breast is perma- 
nently injured. 

The submammary variety is rare ; when present, fever is severe 
and continuous, pus forms slowly, the breast appearing to float 
upon the collection beneath, deep-seated pain is felt in the entire 
organ rather than in distinct sections, and debility with great pros- 
tration accompanies the local condition. 

Results of Puerperal Mastitis.— An attack of " broken breast " 
predisposes to another in a succeeding gestation, on account of 
cicatricial obstruction of the lacteal ducts, and lessened resistance 
to infection from reduction of vitality of glandular epithelia. After 
resolution, lactation, which has usually been arrested during in- 
flammation, may be re-established, but ordinarily is permanently 
lost, for that pregnancy at least, chiefly from failure of the stimulus 
of nursing, which has necessarily been stopped during the disease. 
Mastitis is more likely in those women who have nursed for a 
time but then stopped, than in those who have never nursed at all. 

Treatment — Prophylaxis. — Attempts should be made to abort 
threatened inflammation by entire arrest of nursing, gentle massage 
of the affected breast to relieve milk stasis, and application of 
oleate of atropine, belladonna ointment, icebags, cold coil, or com- 
presses wet with a solution of lead and laudanum. The most 
effective single agent is systematic pressure with ordinary cotton 
batting over which is drawn the Murphy bandage, an opening 



342 THE PRINCIPLES OF OBSTETRICS. 

being left for the nipple. Saline cathartics should be given freely, 
pain relieved by opiates, and fluids denied as much as possible 

Surgical. — When suppuration is evident, the time for procras- 
tinating has passed, and surgical treatment is imperative. Super- 
ficial abscesses should be incised at once; glandular abscess 
opened, to anticipate extension to other lobules, in the following 
manner : Under complete anaesthesia a free opening, outside the 
areola, to prevent a disfiguring scar, and radiating from the nipple, 
so that ducts are not cut across, should be made into the most 
prominent part of the collection. All pockets must be broken up 
with the finger, the cavity washed out with peroxide of hydrogen, 
decinormal salt solution, or weak bichloride, a gauze drain inserted 
to the bottom of the wound, the entire breast enveloped with thick 
absorbent cotton, and the Murphy bandage snugly fastened over 
all. Under this radical method combined with daily irrigation of 
the cavity and energetic supportive medication, the breast usually 
heals within two weeks, but after the old plan of simple puncture 
suppuration may last for months. Though the operation, as de- 
scribed, may seem to the general practitioner needlessly severe, 
experience has abundantly demonstrated its usefulness and safety. 

When symptoms indicate the submammary variety, an aspira- 
tor needle should be passed under the edge of the breast, and if 
pus is found, an incision made at this point, the cavity cleansed, 
and drainage tubes inserted to assist the discharge; otherwise 
treatment is similar to that already given. 

With these grave forms of mastitis, constitutional treatment 
should be vigorous and most sustaining. Nursing from either 
breast should be entirely stopped; from the diseased gland, be- 
cause its milk, being infected, is likely to disturb the child's di- 
gestion, or cause serious and even fatal gastritis or enteritis ; from 
the sound gland, because the irritation of suckling upon that side 
is liable to aggravate engorgement in the other, owing to the ex- 
treme degree of sympathy between them. 

SUBINVOLUTION. 

In quite a proportion of women involution, or the process of 
restoration of the puerperal uterus to the non-gravid condition, is 
retarded, the resulting state being called " subinvolution " 



DISEASES OF BREASTS. 343 

Etiology. — The chief causes are: (i) Anything which inter- 
feres with contractility of the uterus; and (2) as a result lessens 
its blood supply. Immediate causes for the first are displace- 
ments, tumors, and inflammation of the uterus ; retention of frag- 
ments of placenta, secundines, and coagula, which may become 
organized into polypoid growths, and adhesions from pelvic peri- 
tonitis ; for the second, hyperplasia of the endometrium, metritis 
and endometritis, uterine displacements and occasionally small 
fibroids, lacerations of the cervix, retention of decidual and pla- 
cental debris, too early getting up and resumption of sexual inter- 
course, certain diseases of the liver, and valvular heart lesions. 

Diagnosis. — The most significant indication is uterine enlarge- 
ment beyond that of the healthy organ at specified days of the 
lying-in. Thus from the seventh to ninth day after labor the 
normal fundus is from two to four fingers' breadth above the sym- 
physis, and from the tenth to twelfth at or just below its level, 
any decided ascent above these positions, with profuse lochia, in- 
dicating subinvolution. 

Treatment. — The line of treatment depends upon the especial 
cause. When due to endometritis the cavity should be curetted, 
decidual or placental fragments removed in a similar manner, 
fibroids reduced by ergot, strychnine, and electricity, passive con- 
gestion of pelvic and abdominal viscera due to cardiac insufhcieney 
relieved by digitalis, caffeine, strychnine, etc. Routine use of 
ergot is sometimes, not always, beneficial. Appropriate gynaeco- 
logical treatment by local depletion with glycerin, ichthyol, scari- 
fication, irrigation, etc., is important, resumption of active exercise 
and household duties being deferred until normal involution is 
established. 

ACUTE INFECTIOUS FEVERS. 

These are decidedly prejudicial to the mother's interest, and 
fortunately exceptional during the lying-in. Only details of ob- 
stetric interest will be considered. 

Pneumonia. — Acute lobar pneumonia is more likely to compli- 
cate gestation than the puerperium, when its hyperpyrexia and 
interference with fetal oxygenation are apt to cause decidual hem- 
orrhage and premature delivery of a still-born child. Occurring 



344 THE PRINCIPLES OF OBSTETRICS. 

during- the lying-in it retards involution, arrests lactation, and 
from exaggeration of its ordinary effects is quite fatal to the 
mother. Authorities are agreed that the more pregnancy has 
advanced the greater the probability of early interruption of ges- 
tation and the graver the prognosis for both mother and child. 

Treatment. — The chief question of obstetric interest, when 
pneumonia complicates gestation, is the propriety of inducing 
labor, experience showing that relief of the respiratory and excre- 
tory burden of the mother is counterbalanced by the operative 
risks of exhaustion and dangers of infection. Children born dur- 
ing the height of the disease almost invariably die soon after birth. 

Scarlatina, Rubeola, and Variola. — The acute exanthemata 
are infrequent during the puerperium, their course depending upon 
the channel through which infection is received, whether by the 
ordinary inlets (mouth, skin, etc.), or through lesions of the birth 
canal. In the latter case the character of the symptom is practi- 
cal ly that of puerperal septicaemia. 

Scarlatina. — Its course during the lying-in is modified by the 
former condition of the patient, and differentiation between it and 
ordinary puerperal fever is often impossible. Some of its peculiari- 
ties at this time are a short period of incubation, the disease gen- 
erally appearing within the first three days after contagion, slight 
throat complications, early eruption, which spreads quickly over 
the body and is usually deeper in color than common. Pelvic 
peritonitis often accompanies it, and convalescence is likely to be 
prolonged. When the genitals and pelvic organs are but slightly 
affected, prognosis is favorable, although some reporters give a 
maternal fatality of nearly fifty per cent. 

Treatment. — Treatment of the disease is practically similar to 
that in the non-gravid condition, but the patient should be isolated 
and the child removed from her. 

Rubeola and Variola. — Either increases the dangers of the 
lying-in, pneumonia and post-partum hemorrhage being especially 
liable to occur. 

Erysipelas. — The poison of erysipelas is identical with that of 
puerperal septicaemia, from which its diagnosis is impossible unless 
the characteristic skin lesions of erysipelas are present, which is 
exceptional. 



DISEASES OF BREASTS. 345 

Prognosis. — When the disease begins in the face or breast, 
prognosis is ordinarily favorable. 

Treatment. — Cutaneous erysipelas after delivery is treated 
upon general principles, but great care should be taken not to 
permit the genital canal to become infected, nor the child to nurse 
the mother. In the author's case the child, though isolated from 
the mother immediately after characteristic symptoms were dis- 
covered, died of the disease in five days, the mother recovering 
after a frank attack lasting two weeks. 

Malaria. — It is well established that liability to infection with 
the disease is increased after pregnancy, but what influence, if any, 
it has upon the puerperium is unsettled. According to different 
observers fever may be continuous or have decided periodicity, 
appear within the first few days, or be delayed for several weeks. 
The disease inclines to hemorrhage, lessens or entirely arrests lac- 
tation, and "the puerperal state predisposes to grave forms of 
malarial intoxication" (Hirst). 

Diagnosis. — Clinical symptoms alone are misleading, the dis- 
ease being liable to be mistaken for that due to septic infection, 
from which it is differentiated by observing the effect of large 
amounts of quinine upon the fever, and discovery of the plasmodia 
malarias. 

Treatment. — Very large doses of quinine are required to con- 
trol the pyrexia (from forty to seventy-five grains daily), even 
these enormous amounts having apparently no effect upon lacta- 
tion, because the drug is not excreted in the milk. 

Rheumatism and Arthritis. — Puerperal arthritis is either a 
localized septic infection, or, when rheumatoid arthritis, an ac- 
cidental complication with the ordinary disease, diagnosis be- 
tween the latter and the puerperal variety being difficult. Simple 
acute rheumatic fever during the lying-in has the characteristics 
of the common disease. Septic puerperal arthritis, however, 
involves the larger joints, particularly the knee, inflammation is 
continuous, resistant to treatment, of long duration, and gener- 
ally followed by complete ankylosis. Metastatic abscesses in 
joints are associated with other undoubted symptoms of constitu- 
tional sepsis. 

Prognosis, — Its average duration is about three months, an- 



346 THE PRINCIPLES OF OBSTETRICS. 

kylosis of the joint usually follows, and occasionally general tuber- 
culosis in strumous patients. 

Treatment. — Local treatment only promises to be of much 
value, counter-irritation with iodine, blisters, and cautery being 
most useful. The joint must be immobilized, and, after the acute 
attack, massage cautiously employed to retard ankylosis, details of 
special treatment being in accordance with modern orthopedic 
surgery. 

Puerperal Gonorrhoea. — The disease is more common among 
the poor and dissolute than the higher classes, and of especial ob- 
stetric interest from its liability to cause ophthalmia neonatorum. 
Infection by the gonococcus is often combined with that from 
other septic micro-organisms, particularly the streptococcus, giv- 
ing rise to affections of the severest type, metritis, pyosalpinx, 
and pelvic or general peritonitis. 

Diagnosis. — Gonorrhceal infection is probable when the disease 
existed before labor, with well-defined urethritis and vulvovagini- 
tis, and confirmed by finding the gonococcus in the lochia. 

Treatment. — Puerperal infection by the gonococcus is treated 
in a manner similar to that by other micro-organisms. 

GENITO-URINARY SYSTEM. 

Urine. — Immediately after delivery urine of low specific grav- 
ity is decidedly increased in amount, albuminuria and glycosuria 
often are present for a few days, and peptonuria always accom- 
panies the puerperium, the latter increasing up to the fourth day 
and disappearing after the second week. Persistent albuminuria 
is significant of nephritis, which is also manifested by other well- 
known symptoms : headache, pain in the epigastrium, oedema, reti- 
nitis, renal casts, etc. 

Kidneys. — Puerperal diseases of the kidney are inflammatory 
(usually septic) nephritis; metastatic (always septic) nephritis; 
or acute or subacute parenchymatous nephritis; their treatment 
being that of similar diseases in the non-gravid condition. 

Incontinentia Urinae. — Incontinence of urine may be due to 
overdistention of the bladder from neglect of ordinary urina- 
tion, paralysis of the sphincter vesicae resulting from long pressure 



DISEASES OF BREASTS. 347 

by the child's head against it, and fistula in any part of the urinary 
tract from a similar cause, terminating in necrosis and perforation 
into the vagina. 

Diagnosis and Treatment. — Over-distention is recognized by 
the catheter, and needs no other treatment. Paralysis requires 
general treatment by tonics, strychnine, and perhaps local applica- 
tion of electricity. Vesicovaginal and other varieties of urinary 
fistulae require subsequent plastic operations. 

Cystitis. — Inflammation of the bladder is frequent after labor, 
usually septic in origin from infection by an unclean catheter. On 
account of the liability of such infection, it should be an inflexible 
rule never to use a catheter after labor except when absolutely 
necessary, and then only after the most thorough antisepsis of the 
vulva, as directed on page 172. Exceptionally puerperal cystitis 
follows long pressure of the head in vertex presentations. 

Etiology. — The disease begins as a septic inflammation of the 
mucous membrane, infection being carried by an unclean catheter, 
or lochia, into wounds of the urethra and thence into the bladder, 
or received by bladder epithelia which have become devitalized by 
pressure or over-distention. Extension is likely to the ureters and 
kidneys, resulting in a most intractable and even fatal condition. 
Extreme cases of puerperal cystitis ma}- be of diphtheritic origin, 
the mucous membrane become gangrenous and sloughing, frag- 
ments obstruct the urethra, the urine being in such cases puru- 
lent, sanious, horribly fetid, and loaded with albumin and casts. 

Treatment. — The bladder should be irrigated daily with two or 
three pints of decinormal salt or boric-acid solution, diet restricted 
to milk and alkaline liquids, and the strongest supportive treatment 
adopted. Persistent cystitis should be managed by cystoscopy 
and recent methods of intra-vesical treatment. 



CHAPTER IV. 
PATHOLOGY OF THE NEW-BORN CHILD. 

ASPHYXIA NEONATORUM. 

Asphyxia of the new-born child is due to conditions which 
precede or result from labor. 

Ante-partum Causes. — Inspiration of liquor amnii, paralysis of 
the respiratory centre from disturbance of placental circulation 
(premature detachment, obstruction of the cord from coiling, 
compression, or prolapse, disease of funic vessels, extreme uterine 
contractions), injury of the head by pelvic pressure or forceps, 
maternal diseases and hemorrhages, or fetal malformations, espe- 
cially those of the foramen ovale and pulmonary artery. 

Post-partum Causes. — Prevention of respiration by unruptured 
membranes or improper position after birth, and traumatism due 
to precipitate delivery. 

Degree of Asphyxia. — Two stages are accepted — asphyxia livida 
and pallida, the latter being a deepening of the former. 

i . Asphyxia livida, the cyanotic or mild stage, some degree of 
which accompanies nearly every labor but soon passes away under 
appropriate management. The surface is purple, owing to an ac- 
cumulation of carbon dioxide, face congested, the heart and cord 
beat strongly, and reflexes are moderately lessened. 

2. Asphyxia pallida, an intensification of the milder stage, 
much more serious and generally fatal. Circulation is feeble and 
pulse infrequent (about 40 or 50), skin pale reflexes absent, no 
attempts at breathing, and cord pulseless. 

Treatment. — Cleanse the fauces immediately after delivery. If 
there is cyanosis allow a few spurts of the cord, then roll the child 
from side to side, slap it upon the back, sprinkle with cold water, or 
immerse alternately in hot (105°) water, then cold, these combined 
manipulations usually resulting in establishment of respiration. 

348 



PATHOLOGY OF THE NEWBORN CHILD. 349 

If the child is pallid and apparently dead, suspend head down- 
ward to stimulate the brain centres. Try immersion in hot and 
cold water; and if these fail, begin artificial respiration at once. 

Artificial Respiration. — Mouth-to-Mouth Insufflation. — Wipe 
the face of the child with a towel. Cover the mouth and nose 
with the same or a handkerchief. Extend the head by placing a 
roll of cloth under the neck, and breathe slowly into the child's 




Fig. 161.— Byrd-Dew Method. Expiration. 



mouth, at the same time compressing the stomach with one hand 
to prevent its inflation. Do not close the nostrils while insufflat- 
ing, because, when open, too great distention of pulmonary vesi- 
cles is prevented. After each inflation flex the head and compress 
the sides of the chest, repeating the process every five seconds. 
Of all single methods this is the most valuable. 

Byrd-Dew Method. — Hold the child in the palm of each hand, 
allowing the head to fall backward. Supinating the operator's 
arms flexes the body and causes expiration, pronating the arms 



350 



THE PRINCIPLES OF OBSTETRICS. 



extends it, causing - inspiration. This method is especially useful, 
because it can be employed while the child is in a hot bath, and 
manipulation is not injurious. 

Schnltz Method. — Wrap the child's body in a towel to prevent 
chilling - of its surface. Grasp it as shown in the figure, thumb in 
front and fingers behind surrounding the shoulders, the body hang- 




FlG. 162. — Byrd-Dew Method. Inspiration. 



ing face forward in front of the operator. Swing the child out- 
ward and upward, doubling the trunk upon itself, and cause 
expiration. Allow it to unbend by swinging it downward and out- 
ward, the diaphragm and abdominal viscera descending cause 
inspiration. The method is apt to be used in too energetic a man- 
ner, the spine may be injured, the body is likely to be chilled, and 
is not recommended for feeble children. After swinging several 
times, the child should be immersed in a hot bath, when, if thought 
best, the process may be repeated. 



PATHOLOGY OF THE KEW-BORX CHILD. 351 



Laborde Method. — Grasp the tip of the tongue with a haemo- 
static forceps, drawing it forcibly upward against the upper jaw 




Fig. 163.— Schultz Method. Inspiration. 



and out of the mouth eight or ten times each minute. This plan 
can also be used while the child is in a hot bath, and is sometimes 
very efficacious. 



352 



THE PRINCIPLES OF OBSTETRICS. 




Other Methods. — In extreme conditions catheterization of the 
larynx may be tried, care being taken not to injure the trachea 

nor enter the oesophagus ; 
tracheotomy ; dilatation of 
the anus; and electricity, 
one pole being placed over 
the epigastrium and the 
other upon the heart or 
back. 

After-Treatment . — In 
all these cases requiring 
artificial respiration the 
child needs especial atten- 
tion for several hours or 
days to maintain breathing 
and circulation. 'Warmth 
should be supplied by hot- 
water bottles and blank- 
ets, all washing should be 
postponed, and small 
quantities given, by mouth 
or subcutaneously, of whiskey, minute doses of digitalis, or strvch- 
nine. Enemata of two or three ounces of hot decinormal salt 
solution, repeated p. r. n., have apparently saved life after failure 
of other methods. 

TRAUMATISM. 

Brain. — Injury to the brain, usually in the form of meningeal 
hemorrhage, often results from traction or forceps during hard de- 
liveries, causing various degrees of mental impairment in after- 
life, or death, either before or soon after birth. 

Nervous System. — Paralysis of facial or brachial nerves by 
pressure of forceps or traction upon the arm is not uncommon 
after difficult extraction, disappearing after a few days or becom- 
ing permanent, the latter condition being especially probable with 
injury of the brachial trunks (Erb's or Duchenne's paralysis). 

Fractures. — Spoon-shaped depressions or extensive fractures 
of the frontal and parietal bones may be caused by a projecting 



Fig. 164.— Schultz Method. Expiration. 



PATHOLOGY OF THE NEWBORN CHILD. 353 



promontory or blade of the forceps. Distortion of the head from 
moulding is common, its situation being often diagnostic of the 
presentation and position. Favorable results are the rule after a 
time in all these injuries, though severe cranial fractures excep- 
tionally result in permanent lesions of the brain and mental de- 
rangement, sometimes being immediately fatal. 

Fractures of the long bones, or separation of the epiphysis 
from the shaft, are treated in the ordinary manner, those of the 
humerus and clavicle by simply bandaging the arm to the body, 
and of the femur by extension, pasteboard splints, plaster band- 
age, etc. Much ingenuity is sometimes required to overcome 
tendency to displacement, but union generally takes place without 
deformity. 

Caput Succedaneum. — A serous swelling generally develops 
during labor upon the presenting part after rupture of the mem- 
branes, its size depending upon the amount and duration of uterine 
pressure. The location of the caput upon the body indicates the 
original position ; for instance, in vertex anterior positions the ca- 
put lies over the posterior portion of the bregma and vice versa. 
It usually disappears within the first 
twenty-four hours, no treatment be- 
ing required. 

Cephalhematoma. — Once in two 
hundred and fifty labors a tumor de- 
velops within two or three days after 
birth upon the child's head, formed 
by rupture of blood-vessels between 
the bone and pericranium, situated 
ordinarily upon one of the parietals 
or occiput, and bounded by a suture. 
The hemorrhage stimulates- ossifica- 
tion, which is evident in a -hard bony 
ring around the base of the effusion, 
and later by crepitation of the over- 
lying surface-. It- is distinguished from encephalocele by palpation, 
which shows that it does not communicate with the brain, ordina- 
rily is absorbed three or four months after birth, but exceptionally 
suppurates and necrosis of the bone beneath it occurs. 
23 




Fig. 165. — Cranial Depression from 
-Projecting - Promontory. (Her- 
man.) 



354 THE PRINCIPLED OF OBSTETRICS. 

Treatment. — Usually no treatment is required. When, how- 
ever, there is progressive enlargement or persistence of the fluid, 
it may be aspirated or incised under the strictest antisepsis, fol- 
lowed by firm compression to prevent refilling. 

DISEASE. 

Constipation. — Sluggishness of the intestines is largely due to 
lack of fat in the diet. If the child is a nursling, increase the 
quality of the mother's food, and after each feeding give it an 
ounce or more of a mixture of cream and water (one drachm to 
three ounces). If artificially fed, increase the proportion of fat up 
to the limit of digestion, and between feedings give plenty of sim- 
ple lukewarm water. Medicinal laxatives, which should be with- 
held unless absolutely necessary, are Philips' milk of magnesia, 
one to four drachms in each bottle, weak infusions of manna and 
senna, five to ten grains of phosphate of sodium, two to four min- 
ims of fluid extract of cascara, five to ten grains of calcined mag- 
nesia, sweet oil or castor oil. Mechanical laxatives are supposito- 
ries of castile soap, cocoa butter, or glycerin, enemata of castile 
soap and water, using a small soft-rubber syringe, and abdominal 
massage after the morning bath. 

Diarrhoea. — Here, again, the cause is faulty diet. Stop nurs- 
ing or feeding for twelve hours, giving, instead of milk, whey, white 
of egg and water, or dextrinized gruel, according to the directions 
in the Chapter on Artificial Feeding. If the stools are green and 
curdy, use a mild laxative, four or five one-tenth grain triturates 
of calomel and one grain of sodium, calcined magnesia, or ten 
drops of castor oil; if frequent and serous, five to ten grains of 
bismuth, followed by paregoric in a single dose of five or ten min- 
ims. Irrigation of the colon with bicarbonate of sodium or deci- 
normal salt solution is especially useful. 

Indigestion. — The subject has been already considered suffi- 
ciently, but, generally speaking, the diet has too great a propor- 
tion of proteids, which should be varied according to individual 
requirements. "Diluents which have been suggested are whey, 
dextrinized gruel, peptogeriic milk powder, etc. Give triturates 
of calomel and sodium, or a single dose of castor oil, lavage of the 



PATHOLOGY OF THE XmV-BORX CHILD. 355 

stomach being particularly serviceable in babies after the third 
month. 

Colic — The cause is too rapid feeding, too high proportions of 
proteids, fat, and sometimes sugar, too rich breast milk, etc., the 
immediate cause being detected only after careful study of the 
individual habit of nursing or feeding, care of the child, environ- 
ment, and the like. 

Treatment. — The most serviceable drug is chloral, given in one- 
half to one-grain doses with some aromatic water and glycerin 
(not sugar or syrup) ; the old-fashioned milk of asafcetida by mouth 
or enema is also valuable, and warm compresses upon the stomach 
with an occasional plain enema. 

Sprue or Thrush. — The disease is indicated by white aphthous 
patches, scattered about upon the mucous surface of the mouth, 
due to the presence of a fungus (saccharomyces albicans), devel- 
oping in unclean milk. The patches are distinguished from milk 
curds by adhering firmly to the surface, and microscopic examina- 
tion showing the parasite. 

Treatment. — Destroy the growth by saturated solution of boric 
acid or bicarbonate of sodium, applied by a swab of linen upon the 
handle of a spoon or the finger, and treat the accompanying sto- 
matitis by appropriate medication, change of diet, sterilization of 
all feeding apparatus, etc. 

Icterus. — Of the two forms, transient and grave, the first is 
common, appearing on the second or third day as a yellowish hue 
of the conjunctivae and breast. It is due to temporary congestion 
of the liver with failure of biliary excretion by the hepatic ducts 
and resorption of bile, generally disappearing in a few days with- 
out treatment other than a mild cathartic. 

Icterus gravis is much more important, the entire body being 
progressively jaundiced, with discoloration of urine and faeces, 
and is caused by serious organic disease or septicaemia. Treat- 
ment is ordinarily useless. 

Haemophilia.— A disease of the blood, characterized by a ten- 
dency to bleed from the umbilicus and any or all of the mucous 
surfaces; in extreme cases petechiae being scattered about over 
the whole body. The cause is unknown, but it is confined to 
male children, though transmitted by female, who very exception- 



356 TEE PRIXCIPLES OF OBSTETRICS. 

ally have the disease. When general it is incurable, though if 
restricted to the umbilicus attempts to arrest the bleeding (which 
are usually unsuccessful) should be made by pressure, application 
of suprarenal extract or adrenalin, and figure-of-eight ligature. 

Syphilis. —The child may be infected from either or both par- 
ents ; and if the mother has the disease during pregnancy she will 
transmit it to the infant in an acute stage. Periods of latency, in 
which healthy offspring are born, may be followed by renewal of 
virulence, resulting in abortion, miscarriage, or birth of a living 
syphilitic child, but it is believed that after six years ability to 
transmit the disease is no longer present. 

Colics Law. — This principle, first stated in 1837, is still prac- 
tically accepted by syphilographers : "A new-born child affected 
with inherited syphilis, even though it may have specific lesions 
in the mouth, never causes infection of the breast which it sucks, 
if it be the mother that nurses it, although continuing capable of 
infecting a strange nurse." 

Symptoms. — Active symptoms may be present at birth, or 
postponed for several months ; but, as a rule, the earlier syphilis 
appears the graver the prognosis. Occasionally the child has the 
disease at birth, but characteristic symptoms are usually deferred 
for four or five weeks, the initial lesion being coryza (" snuffles "), 
excoriation or ulceration of the upper lip resulting from the acrid 
discharge. Emaciation is progressive, the child looking prema- 
turely aged; fretfulness, indigestion, fissures of the mouth and 
anus (rhagades) are likely. Visceral and bone lesions are early 
constitutional manifestations. Macular, papular, or pustular erup- 
tions, the latter affecting especially the palms and soles, are local 
characteristics. When of late appearance the disease is less viru- 
lent, and all symptoms ma}- be slight 

Treatment. — The best internal treatment is by calomel and 
chalk, one-twelfth grain morning and evening and gradually in- 
creased, or calomel alone, which is more rapid in effect, one-twen- 
tieth to one-sixth grain twice daily. Many authorities prefer the 
method of inunction, either bv rubbing a piece of mercurial oint- 
ment as large as a filbert upon the child's binder every other day, 
or the same amount upon the inside of the thighs or in the arm- 
pit. A more cleanly preparation than the ointment is the oleate 



PATHOLOGY OF THE NEW-BORN CHILD. 357 

of mercury in ten-per-cent solution, using it in a similar manner. 
Syphilitic parents should be placed upon active specific treatment. 
Tetanus. — Infection by the tetanus bacillus enters usually 
through the unhealed umbilicus, ordinary symptoms appearing at 
the beginning of the second week. Treatment is according to 
that at any other period of life, but the disease is nearly always 
fatal after a few days. 

DISEASES OF THE UMBILICUS. 

The umbilicus is liable to become infected, while healing, from 
septic material upon the hands of the nurse, or neglect of ordinary 
cleanliness, resulting in local ulceration, umbilical phlebitis, or 
general septicaemia. Cellulitis about the navel, peritonitis, and 
metastasis to remote organs are frequent and usually fatal com- 
plications. 

Treatment. — Local infection should be arrested by cleansing 
the wound with peroxide of hydrogen and application of bismuth, 
calomel, boric acid, acetanilid, etc., general infection being com- 
monly fatal under any form of management. 

Fungus. — Granulations in the stump of the cord may develop 
into fungoid growths, growing to the size of a pea, and are removed 
by cauterization with solid nitrate of silver. Occasionally a 
persistent growth is found upon microscopic examination to 
be the remains of the omphalo-mesenteric duct (a very early 
embryonic structure, which connects the intra- and extra-abdominal 
portions of the umbilical vesicle). Treatment is excision after 
ligation, a similar operation being required for persistent stump 
of the cord. 

Hemorrhage. — Bleeding from the cord (omphalorrhagia) 
results from defective ligation, sepsis, syphilis, or grave sys- 
temic disease (haemophilia), appears soon after birth, and is 
very fatal. 

Treatment. — In non-specific cases the cord should be retied, 
or each vessel ligated separately if possible. When, as is usual, 
this fails, transfix the umbilicus with hare-lip pins or long needles, 
surrounding these with a figure-of-eight ligature of silk, taking 
care not to include in it a loop of intestine. 



358 THE PRINCIPLES OF OBSTETRICS. 



HEMORRHAGES AND MASTITIS. 

Melena or Gastro-Intestinal Hemorrhage. — Extravasation of 
blood into the stomach or intestines is a rare affection of the new- 
born child, appearing once in about eight thousand births, usually 
on the second day. 

Etiology. — In a majority of cases the disease is supposed to be 
of infectious origin, asphyxia being a predisposing cause, or due to 
duodenal ulcer, some congenital defect which increases intra-ab- 
dominal pressure, intussusception, or haemophilia. 

Symptoms. — Blood from the intestines is black from admixture 
with meconium (the color giving the name " melena " to the dis- 
ease), but when vomited is bright red or resembles coffee 
grounds. If hemorrhage continues, lowered temperature, col- 
lapse, and other signs of internal bleeding follow. Prognosis is 
generally unfavorable, mortality being about fifty per cent. 

Treatment. — Gallic acid, two grains every hour, chloride of 
calcium, one to two grains often, hypodermics of ergotin, heat to 
the flanks and ice-bag upon the abdomen, but any form of treat- 
ment is ordinarily ineffectual. 

Hemorrhage from the Genitals. — Female infants often have a 
discharge of blood from the genitals a few days after birth, which 
has been demonstrated to be a true menstruation. It continues 
only a short time and requires no treatment. 

Mastitis. — The breasts of new-born, especially male, children 
often become swollen and exceptionally suppurate. Contrary to 
general belief of the laity no professional treatment is needed, un- 
less abscess, resulting from improper manipulation, requires 
lancing. 



INDEX 



Abdomen, changes in, after labor, 

171 
Abdominal gestation, 112 
Abortion, 100 

diagnosis of, 103 

complete or incomplete, 103 
ectopic pregnancy, 104 
inevitable, 103 
threatened, 103 
etiology of, 100 
fetal, 101 
local, 100 
maternal, 100 
paternal, 100 
frequency of, 100 
prognosis of, 104 
symptoms of, 10 r 

actual, before formation of 

placenta, yoi 
after formation^ placenta, 

102 
complete, 102 
incomplete, 102 
inevitable, 101 
threatened, 10 r 
treatment of, 104 
incomplete, 105 
inevitable, 104 
threatened, 104 
varieties of, 100 
Accidental hemorrhage complicat- 
ing labor, 295 
Adherent placenta as cause of hem- 
orrhage, 305 
After-pains, 169, 172 
Albuminuria, 89, 90 



Allantois, 36 
Amenorrhcea, 47 

symptom of pregnancy, 47 
Amnion, 36 

and liquor amnii,diseasesof, 118 
hydramnios, 119 
oligohydramnios. 118 ■ 
polyhydramnios, 119 
Anaesthesia during labor, 156, 158 
Anencephalus, 251 
Anomalies in shape of placenta. 121 
Apoplexy of placenta, 121 
Arthritis during puerperium, 345 
Artificial feeding, 182 

respiration in asphyxia neona- 
torum, 349 
Asphyxia neonatorum, 348 
causes, ante partum, 348 

post partum, 348 
degree of, 348 

asphyxia livida, 348 
asphyxia pallida, 348 
treatment, 348 

artificial respiration, 349 
after-treatment, 352 
Byrd-Dew method, 

349 
Labof4e method, 351 
mouth-to-fnouth in- 
sufflation, 349 
Schultze method, 550 
other methods, 352 
Assimilation of substitute feeding, 

practical hints for, 187 
Atresia of vagina, 216 
of vaginal outlet, 216 



360 



INDEX. 



Attitude, definition of, 135 
Axis-traction forceps, 264, 273 
rods, 264, 274 

Bacteriology of puerperal fever, 

325 
Bartholin, glands of, 15 
Binder applied after labor, 164 
Breast, diseases of, during the puer- 
perium, 340 
milk, 178 

food value of, 180 
pumps, 190 
Breasts, care of, during pregnane}-, 

74 
changes in, after labor, 171 

during pregnancy, 48, 51, 
58 " 
Breech presentation, 226. See Foe- 
tus .or passenger, irregularities 
in. 
Brow presentations, 225 
Byrd-Dew method of artificial respi- 
ration, 349 

Cesarean section, 279 

comparison between symphy- 
seotomy, craniotomy, and, 281 
contraindications, 28 1 
for placenta prsevia, 299 
hysterectomy, 2S3 
indications, 280 
technique of operation, 281 
abdominal incision, 282 

sutures, 2S3 
after-treatment, 2S4 
uterine incision, 2S3 
sutures, 283 
time for operation, 281 
varieties of methods, 2S0 
Sanger's, 280 
Cancer, syncytial, 117 
Caput succedaneum, 353 
Carus, curve of, 7 
Catheterization after labor, 173 



Cephalhematoma, 353 
Cervical occlusion, 215 

rigidity, 215 
Cervix, lacerations of, during labor, 

310 
Chamberlain forceps, 263 
Changes in the reproductive system 

during the puerperium, 169 
Child-bed fever, 325 
Chorion, 37 

diseases of, 115 

cystic degeneration of villi, 

115 
Circulation of foetus, 44 
Clitoris, 15 

Cceliohysterotomy, 279 
Colic in new-born child, 355 
Compound presentations, 242 
Compression of uterus to prevent 

hemorrhage after labor, 302 
Conception, 32 

Constipation in new-born child, 354 
Contracted pelvis from coxalgia, 213 
Cord, umbilical, 39 
Corpus luteum, 31 
Cow's milk, composition of, 182 
Curve of Carus, 7 
Cystitis during the puerperium, 347 

Decidua, 36, 38 
Deciduse, diseases of, 120 

hydrorrhcea gravidarum, 120 
specific endometritis, 120 
Defecation after labor, 173 
Deformities of the pelvis, 196, 204 
classification, 197 
frequency, 196 
general diagnosis, 197 
of hard parts, 196, 204 
. contracted, rare forms of, 
207 
fetal, female or male, 

207 
from coxalgia, 213 
kyphotic, 208 



INDEX. 



361 



Deformities of the pelvis, of hard 
parts, malacosteon, 

211 

Naegele's, 211 
osteomalacia, 211 
rachitic, 20S 
Robert's, 211 
spondylolisthetic, 212 
tumors of pelvic inte- 
rior, 213 
generally flat contracted 

non-rachitic pelvis, 207 
justo-major pelvis, 206 
justo- minor pelvis, 206 
simple flat pelvis, 204 

mechanism of labor in, 
204 
of soft parts, 214 

atresia of vagina, 216 

of vaginal outlet, 216 
incarceration of anterior 

uterine lip. 216 
irregularities in develop- 
ment of uterus, 214 
occlusion of cervix, 215 
rigidity of cervix, 215 
solid tumors of birth canal, 
216 
palpation of pelvic interior, 203 
pelvimetry, 198 
Dextrinized gruel for artificial feed- 
ing, 185 
Diagnosis of approaching labor, 149 
Diameters of fetal body, 135 
of fetal head, 134 
pelvic, 134 
Diarrhoea in new-born child, 354 
Diet after labor, 174 
Diseases of foetus and appendages, 

115 
of amnion and liquor amnii, 118 
of chorion, 115 
of deciduae, 120 
of foetus, 122 
of placenta. i2j 



Diseases of placenta, syncytial can- 
cer, 117 
Diseases of umbilical cord, 122 
Diseases of new-born child, 354 
colic, 355 
constipation, 354 
diarrhoea, 354 
haemophilia, 355 
icterus, 355 
indigestion, 354 
sprue or thrush, 355 
syphilis, 356 

Colles' law, 356 
tetanus, 357 
Diseases of pregnancy, 76 
Diseases of the umbilicus, 357 
fungus, 357 
hemorrhage, 357 
Disorders of pregnancy, 76 
of birth canal, 77 
of cervix, 80 
cancer, 80 
inflammation, 80 
pruritus, 81 

vegetations about vulva, 82 
of circulatory system, 93 
blood, 95 

anaemia, 95 
plethora, 95 
heart, 93 
hemorrhoids, 94 
palpitation and fainting, 95 
varices, 94 
of digestive system, 83 
of liver, 89 

acute yellow atrophy, 89 
of intestines, 88 

appendicitis, 89 
constipation, 88 
diarrhoea, 88 
of mouth, 83 

ptyalism, 83 
toothache, 83 
of stomach, 38 

nausea and vomiting, 83 



362 



INDEX. 



Disorders of pregnancy, of perni- 
cious vomiting, 85 
of general system, 97 

infectious diseases, 97 
cholera, 98 
enteric fever, 98 
malaria, 98 
rubeola, 98 
scarlatina, 99 
syphilis, 99 
typhus fever, 98 
variola, 98 
varioloid, 98 
yellow fever, 98 
of nervous system, 96 

cerebral and spinal disease, 

96 
chorea, 96 
epilepsy, 96 
insanity, 96 
neuralgias, 96 
of respiratory system, 92 
dyspnoea, 92 
lungs, 92 

phthisis pulmonalis, 92 
pneumonia, 92 
of skin, 99 

herpes, 99 
pruritus, 99 
of urinary system, 89 
of bladder, 91 

glycosuria, 91 
hsematuria, 92 
incontinence, 92 
irritability, 91 
of kidney, 89 

kidney of pregnancy, 

89 
true nephritis, 89 
of uterus, 76 

displacements, 76 
inclusion of, within a her- 
nia, 80 
metritis, 80 
new growths in, 80 



Disorders of pregnancy, of uterus, 
retroversion and retroflexion, 
76 
of vagina, 81 

gonorrhceal vaginitis, 81 
leucorrhcea, 81 
of vulva, 81 
Dressing the child after labor, 176 

umbilical cord, 175 
Duration of labor, 147 

of pregnancy, 63, 64 
Duverney, glands of, 15 
Dystocia, 147 

Eclampsia, 335 

attack the, 336 
differential diagnosis, 336 
etiology, 335 
frequency, 335 
premonitory symptoms, 336 
prognosis, 336 
prophylaxis, 90, 337 
treatment, 337 

obstetrical, 338 

of eclampsia after via- 
bility, 338 
of eclampsia after de- 
livery, 339 
of eclampsia before via- 
bility, 338 
therapeutic, 337 
Ectopic pregnancy, abortion in, 104 
Embryo, growth of, by month, 42 
Embryology, 33 
allantois, 36 
amnion, 36 
chorion, 37 
decidua, 36, 38 
umbilical vesicle, 35 
vitelline duct, 35 
Embryotomy, 288 
amputation, 29T 
craniotomy, 291 
decapitation, 291 
evisceration. 2gi 



INDEX. 



363 



Embryotomy, extraction of decapi- 
tated head, 291 
indications, 288 
instruments required, 288 
technique of operation, 289 

Encephalocele, 251 

Entocia, 147 

Episiotomy, 161 

Ergot, to prevent hemorrhage in 
third stage of labor, 164 

Erysipelas, during the puerperium, 

344 
Etiology of labor, 148 
Extra-uterine pregnancy, 109 
abdominal gestation, 112 
classification of, 109 
diagnosis of, 112 

after rupture, 112 
before rupture, 112 
differential, 113 
etiology, no 

extraperitoneal rupture, in 
intraperitoneal rupture, 112 
pathological history, in 
symptoms; no, prognosis, 113 
after rupture, in 
before rupture, no 
treatment, 1 13 

Csesarean section, 113 

Face presentations, 222 
Fallopian tubes, 22 

anatomy of, 22 
False mole, 116 

Feeding of new-born infant, 176 
Female sexual organs, 13 
Fever, puerperal, 325. See Puer- 
peral fever 
Flat, contracted, non-rachitic pel- 
vis, 207 
Fetal circulation, 44 

difference from that of child, 45 
Fetal head, diameters of, 134 

membranes, 36 

pelvis, 207 



Fetal skull, at birth, 132 
diameters of, 134 
fontanels, 133 

anterior, greater, or breg- 
ma, 133 
occiput, 134 
parietal, 134 
posterior or lesser, 133 
protuberances, 134 
sinciput, 134 
sutures, 132 
vertex, 134 
Fetal development, irregularities 
in, 243 
anencephalus, 251 
encephalocele, 251 
extreme development of foetus, 

247 
hydrocephalus, 249 
membranes, 253 
multiple births, 243 

influence upon labor, 244 
varieties of irregular posi- 
tions in, 244 
premature ossification of the - 

head, 250 
tumors, 253 
umbilical cord, 254 

irregularities in length of, 

254 
prolapse of, 254 
rupture of, 256 
Wormian bones, 250 
Foetus at birth, 131 

circulation in, 44 
Foetus, diseases of, 122 
death in utero, 122 

etiology, treatment, 123 
infectious diseases, 122 
Foetus, growth of. by month, 42 
Foetus or passenger, irregularities 
in, 218 
breech presentation, 226 
axioms in, 237 
delay from feeble pains, 232 



364 



INDEX. 



Foetus, breech presentation, delay 
from disproportion, 233 
delivery of arms, 234 

after-coming head, 236 
Derventer's method in low 
arrest of head and arms, 
235 
diagnosis of, 229 
etiology of, 226 
fillet, 233 

forceps in breech extrac- 
tion, 234 
frequency of, 226 
mechp.'rism of delivery in, 
227 
irregularities of, 229 
method of bringing down 

one leg, 232 
nuchal arm, 235 
positions, 227 

Prague method in high ar- 
rest, 236 
prognosis, 230 
treatment. 230 
brow presentations, 225 
compound presentations, 242 
face presentations, 222 

treatment, 224 
occipito - posterior positions, 
218 
treatment, 219 
transverse presentations, 238 
treatment, 241 
Follicles, Graafian, 30, 31 
Fontanels at birth, 133 
Forceps, 263 

axis-traction, 264 

application of, 273 
rods, 264, 274 
Chamberlain, 263 
function of, 264 
general contraindications, 266 
general indications for, 265 
defect in passages, 265 
in passengers, 266 



Forceps, general defect in powers, 
265 
Hodge, 263 
Levret, 263 

posture in forceps delivery, 257 
lithotomy position, 269 
Walcher position, 269 
preparation for forceps, 267 
removal of forceps, 274 
Smellie, 263 
Simpson, 263 

application of, vertex pres- 
entation O. L. A., 269 
extraction, 270 
Formulas for preparation of dextrin- 

ized gruel, 185 
Fracture and diastasis of pelvic ar- 
ticulations during labor, 308 
Fungus of umbilicus in new-born 

child, 357 
Funnel pelvis, 207 

Gastrointestinal hemorrhage in 

new-born child, 359 
Gavage for infant feeding, 189 
Genito-urinary system during the 
puerperium, 346 

cystitis, 347 

incontinence of urine, 346 

kidneys, 346 

urine, 346 
Germinal spot of ovum, 31 
Glands, Bartholin's, 15 

Duverney's, 15 

mammary, 24 

vulvo-vaginal, 15 
Gonorrhoea, puerperal, 346 
Graafian follicles, 31 

retrograde changes in, 31 

ripening of, 31 

structure of, 31 
Growth by month of embryo and 

foetus, 42 
Gruel, dextrinized, for artificial 
feeding, 185 



INDEX. 



365 



H/Emophilia in new-born child, 355 
Hemorrhage, accidental, during la- 
bor, 295, 300 
diagnosis, differential, 301 
etiology, 300 
frequency, 300 
prognosis, 301 
symptoms, 300 
treatment, 301 
unavoidable, 295 
varieties, 303 

apparent, 300 
concealed, 300 
Hemorbage from genitals in new- 
born child, 358 
from umbilicus in new-born 
child, 557 
Hemorrhage, post-partum, from 
uterine inertia, 302 
etiology, 502 
symptoms, 302 
treatment, 302 

minor details of, 304 
of acute anaemia after 

flooding, 305 
prophylactic, 302 
with active flooding, 303 
puerperal, 302 

hsematoma, 306 
secondary, 306 
etiology, 306 
treatment, 306 
vulvo-vaginal thrombosis, 
306 
clinical history, 307 
diagnosis, 307 
etiology, 306 
prognosis, 307 
situation, 306 
treatment, 307 
treatment after labor, 

307 
treatment during labor, 
307 
treatment, prophylactic, 307 



Hemorrhage, prevention of, in third 

stage of labor, 163 
Hodge forceps, 263 
Hydatidiform mole, 116 
Hydramnios, 119 
Hydrocephalus, 249 
Hydrorrhcea gravidarum, 120 
Hygiene of pregnancy, 73 
Hymen, 17 

varieties of, 17 

Icterus in new-born child, 355 

Impregnation, 32 

Incarceration of anterior uterine 

lip, 216 
Incontinence of urine during the 

puerperium, 346 
Incubator for premature infants, 

187 
Indigestion in new - born child, 

354 
Induction of labor, 259, See Labor, 

induction of. 
Inertia of uterus during labor, 
194 

differential symptoms, 194 

obstructed labor, 194 

primary, 194 

prognosis, 195 

secondary, 194 

treatment, 195 
Infectious diseases during preg- 
nancy, 97 
Infectious fevers, acute, during 
the puerperium, 343 

arthritis, 345 

erysipelas, 344 

gonorrhoea, 346 

malaria, 345 

pneumonia, 343 

rheumatism, 345 

rubeola, 344 

scarlatina, 344 

variola, 344 
Insufflation, mouth-to-mouth, 349 



366 



INDEX. 



Inversion of puerperal uterus, 320 
diagnosis, 320 
etiology, 320 
prognosis, 320 
treatment, 320 

difficult cases, 321 
Involution, 169 
Irregular development of uterus, 

214 
Irregularities in mechanism of la- 
bor, 193 
passages, the, 196 

hard parts, the, 196-214 
soft parts, 214-217 
passengers, the, 218-255 
powers, the, 193-.96 

Justo-major pelvis, 206 
Justo-miuor pelvis, 206 

Kidneys during the puerperium, 346 
Kyphotic pelvis, 208 

Labia majora, 13 

minora, 14 
Labor, 147 

antiseptic preparations for 
house, 152 

definition of, 147 

diagnosis of approaching, 149 

duration of, 147 

etiology of, 147 

instructions when to send for 
physician and nurse, 151 

irregularities in mechanism of, 

193 
list of articles for, 150 
management of normal, 150 
obstetric handbag, 151 
ph}-siology of, 147 
precipitate, 193 
preparations for, 147 
protracted or tedious, 193 
stages of, 127. See Stages of 

labor. 



Labor, conduct of, i 53 
first stage, 153 

abdominal examination, 153 

anaesthesia, 156 

minor details, 156 

preparation of room ■ and 
bed, 153 

toilet of birth canal, 154 

vaginal examination, 155 
second stage, 157 

anaesthesia, 158 

episiotomy, 161 

ligation of cord, 162 

management of perineum, 

159 
position of patient, 157 
rupture of membranes, 158 
treatment of new-born 
child, 162 
third stage, 163 

care after delivery, 167 
delivery of placenta, 165 
prevention of hemorrhage, 
163 
binder, 1 64 
ergot, 164 

manual uterine com- 
pression, 164 
toilet after delivery of pla- 
centa, 167 
Labor, induction of, 259 
indications for, 259 
methods, 259 

Diihrssen's incisions, 261 
hydrostatic dilators, 261 
Krause method, 259 
manual dilatation, 260 
separation of membranes, 

260 
summary of methods, 262 
tamponade, 260 
therapeutic, 259 
treatment of the immature 
child, 260 
Labor, mechanism of, 127 



INDEX. 



36' 



Labor, mechanism off actors of, 127 
passages, 131 
passengers, 131 

articulations between 

head and spine, 135 
classification of pres- 
entations and posi- 
tions, 135 
definitions, 135 
diameters of fetal body, 

135 
diameters of fetal head, 

134 
dimensions of foetus, 

131 
fontanels, 133 
sutures, 132 
powers of, in first stage, 127 
in second stage, 129 
in third stage. 130 
Laborde method of artificial respira- 
tion, 351 
Lacerations of birth canal, 310 
of cervix, 310 
etiology, 310 
symptoms, 310 
treatment, 310 
of perineum, 312 
frequency, 312 
symptoms, 312 
treatment, 312 

final technique, 314 
immediate perineorrha- 
phy, 313 
of complete lacerations, 

314 

of first and second de- 
grees, 313 

repair by granulation, 

3i5 
varieties, 312 
of vagina, excluding perineum, 

311 
Levret forceps, 263 
Ligaments of ovaries, 24 



Ligaments of uterus, 22 
List of articles for labor, 150 

of baby clothing, 150 
Lochia, the, 170, 172 
Lymphatics of external sexual or- 
gans, 16 

Malacostea pelvis, 211 

Malaria during the puerperium, 345 

Male pelvis, 207 

Mammary engorgement, 179 

glands, 24 
Management of normal labor, 150, 

153 
Mastitis, 340 

etiology, 340 
diagnosis, 340 
results of, 341 
symptoms, 340 
treatment, 341 

prophylactic, 341 
surgical, 341 
Mastitis in new-born child, 358 
Mechanism of labor, 127 
Melena in new-born child, 358 
Menopause, 30 
Menstruation, 29 

amount of discharge, 29 
composition of discharge, 29 
menopause, 30 
periodicity of, 29 
puberty, 29 

symptoms accompanying, 29 
vicarious, 29 
Methods of inducing labor, 259 

of resuscitation in asphyxia neo- 
natorum, 352 
Metria, 325 
Milk, cow's, 182 

amount required daily dur- 
ing first year, 182 
preparation of, 182 
variations in secretion of, 174 
Miscarriage, 100, 108 
Mixed nursing, 181 



'Mis 



IXDEX. 



Mons veneris, 13 
Multiple births, 243 
Murphy bandage, 1S0 

Naegele's pelvis, 211 
Nerves of external sexual organs, 
16 
of uterus, 22 



Nucleus of ovum, 31 
Nursing and substitute 
174, 17S 
nursing, 178 



feeding. 



breast milk, 178 
estimation of food value of 

breast milk, 1S0 
m a m m a r y engorgement, 

179 
mixed nursing, 1S1 
Murphy bandage, 1S0 
technique of nursing, 179 
wet-nursing, 1S1 
substitute feeding, 1S2 

assimilation of, practical 

hints for, 187 
breast pumps, 190 
cow's milk, 182 

comparison with hu- 
man, 1S2 
composition of, 1S2 
daily amount during 

first year. 1S2 
percentage feeding, 1S3 
percentage feeding, 
home modification of, 
187 
preparation of, 1S2 
dextrinized gruel, 1S5 

administration of. 1S6 
formulas giving quanti- 
ties for t .venty-ounce 
mixtures, 1S5, 186 
gavage, 1S9 

incubator for premature in- 
fants, 187 



Nursing, substitute feeding, nurs- 
ing-bottles and nipples, 
189 
whey, how to make, 1S4 

Nursing-bottles and nipples, 189 

Obstetric handbag, 151 
Occipito-posterior positions, 218 
Oligohydramnios, n3 
Omphalorrhagia, 357 
Organs, sexual, 13 
external, 13 
clitoris, 15 
labia majora, 13 
labia minora, 14 
lymphatics of, 16 
mous veneris, 13 
nerves of, 16 
vessels of, 16 
vestibule, 15 
vulvo- vaginal glands, 15 
internal, 17 

Fallopian tubes, 22 
hymen, 17 

mammary glands, 24 
ovaries, 23 
urethra, iS 
uterus, 19 
vagina, i3 
Osteomalacic pelvis, 211 
Ovaries, 23 

ligaments of, 24 
Overdevelopment of foetus, 247 
Ovulation, 30 
Ovum, 30 

classification of membranes of, 

35 
development of fertilized, 33 
organs derived from membranes 

of, 35 
segmentation of, 33 
structure of, 30, 31 

Pathology of new-born infant, 348 
Pelvis, anatomv of, 3 



INDEX. 



369 



Pelvis, articulations of, 9-12 
axis of, 7 
deformities of, 196-204. See 

Deformities of the pelvis. 
diameters of, 7, 134 
at outlet, 8 

antero-posterior, 8 
transverse, 8 
external, 8 

Baudelocque's, 8 
bitrochanteric, 9 
conjugate, 8 
intercristal, 8 
interspinous, 8 
in cavity, 8 

antero-posterior, 8 
transverse, 8 
internal, 7 
at brim, 7 
antero-posterior, 7 
first oblique, 8 
second oblique, 8 
transverse, 8 
false, 5 
floor of, 9 
muscles of, 9 
obstetric, definition of, 3 
planes of, 7 
soft parts of, 9 
true, 5 

importance of shape in 
childbirth, 5 
Pelvimetry, 198 

Collyer's instrument, 198 
method of performing, 19S-202 
Percentage feeding, 183 

home modification of, 1S7 
Perineum, lacerations of, during la- 
bor, 312 
management of, during labor, 

159 
Physiology of pregnancy. 26 

of the puerperium, 168 
Placenta, 39 

adherent, 305 
24 



Placenta, circulation in, 40 

composition of, 40 

delivery of, 165 

development of, 39 

functions of, 41 

situation of, 41 

surfaces of, 39 
Placenta, diseases of, 121 

anomalies of shape of, 121 

apoplexy of, 121 

infarctions in. 121 

placentitis, 121 

syphilis of, 121 
Placenta prsevia, 295 

Csesarean section for, 299 

cause of hemorrhage, 297 

characteristics of different 
forms, 296 

clinical history of, 296 

diagnosis of, 297 

etiology of, 296 

frequency of, 295 

influence of, on labor. 297 

prognosis, 298 

treatment, 298 

after viability, 298 
before viability, 298 
management of third stage, 
299 
Placentitis, 121 
Pneumonia during the puerperium, 

343 
Polyhydramnios, 119 
Position, definition of, 135 
Positions of foetus, 136 

classification of. 136 

diagnosis of, 140 

frequency of, 137 

prognosis of, 143 
Post-mortem delivery, 30S 
Post-partum hemorrhage from ute- 
rine inertia, 302 
Powers of labor, irregularities in, 

193 
deficient power, 193 



370 



INDEX. 



Powers of labor, deficient power, 
etiology of, 194 

prognosis of, 195 

treatment of, 195 

varieties of inertia, 194 
extreme power, 193 

precipitate labor, 193 
dangers, 193 
treatment, 193 
Precipitate labor, 193 
Pregnancy, diagnosis of, 46 

differential diagnosis of, 63, 67 

ascitis, 68 

distended bladder, 69 

extra-uterine gestation, 67 

fibromata, 68 

haematometra, 69 

hydrometra, 69 

inflammatory growths, 67 

obesity, 68 

ovarian cystomata, 68 

physometra, 69 

pseudocyesis, 69 
disorders of, 76 

birth canal, 76 

circulatory sj'Stem, 93 

digestive system, 83 

infectious diseases, 97 

nervous system, 96 

respiratory system, 92 

skin diseases, 99 

urinary system, 89 
duration of, 63 

Naegele's law for computa- 
tion of, 64 
ectopic, abortion in, 104 
extra-uterine, 109. See Extra- 
uterine pregnancy . 
hygiene of, 73 

bathing, 74 

birth canal, 75 

breasts and nipples, care 
of, 74 

defecation and urination, 74 

diet, 73 



Pregnancy, hygiene of, dress, 74 
exercise, 73 

infection, dangers of, 75 
marital relations, 75 

irregularities of, 63 
missed labor, 64 
multiple pregnancy, 65 
Naegele's law, 64 
prolonged pregnancy, 65 
pseudocyesis, 66 
signs of recent delivery, 65 

physiology of, 26 
Pregnancy, symptoms of, 46 

abdominal enlargement, 52, 59 

amenorrhcea, 47 

ballottement, 56, 59 

bluish color of external genitals, 

57 

changes in cervix, 49, 60 

in size and position of ute- 
rus, 49, 6 j 

choc fetal, 57 

classification of symptoms for 
each trimester, 61 

colostrum, 58 

constipation, 59 

definition of fetal parts, 60 

dysuria, 59 

fetal heart sounds, 55 

funic bruit, 56 

gastric disturbances, 48, 51 

Hegar's sign, 49 

in first, second, and third tri- 
mester, 47, 50, 58 

lightening, 58 

mammary changes, 48, 51, 58 

milk, 58 

movements of foetus in utero, 

59 

nervous irritability, 48 

pigmentation, 53 

quickening, 53 

strise gravidarum, 59 

uterine changes in size and po- 
sition, 49, 6c 



INDEX. 



371 



Pregnancy, uterine contractions, 
intermittent, 57 
souffle, 56 
varicosities, 59 
Premature infants, incubator for, 
187 
labor, 100, 108 

ossification of fetal head, 250 
Preparation for labor, 148 

antiseptic, 152 
Presentation, definition of, 135 
Presentation of foetus, 137 
abnormal, 136 
breech, 136 
cephalic, 136 
diagnosis of, 140 
face, 136 

frequency of, 137 
longitudinal, 136 
natural, 136 
normal, 136 
prognosis of, 143 
unnatural, T36 
vaginal signs of, 142 
breech, 143 
brow, 143 
face, 143 
hand or foot, 143 
knee and elbow, 143 
transverse, 143 
vertex, 142 
Protracted labor, 193 
Puberty, 29 

Puerperal convulsions, 335 
Puerperal fever, 325 
bacteriology, 326 
chanuels of infection, 327 
diagnosis, 327 
etiology, 326 
frequency, 326 
history, 325 
prophylaxis, 328 
results of infection, 327 
sources of infection, 326 
special lesions of, 329 



Puerperal fever, special lesions of, 
cellulitis, 331 
cystitis, 333 
endometritis, 329 
metritis, 330 
milk leg, 332 
peritonitis, 330 
diffuse, 331 
pelvic, 331 
phlegmasia alba dolens, 332 
pyaemia, 333 
pyelitis, 333 
salpingitis, 329 
saprsemia, 333 
septicaemia. 333 
ureteritis, 333 
vaginitis, 329 
symptoms, 327 
treatment, 328 

constitutional, 329 
local, 328 
Puerperium, the, 168 

changes in the reproductive sys- 
tem during the, 169 
abdomen, 171 
after-pains, 169 
breasts, 171 
lochia, 170 
involution, 169 
other associated structures, 

171 
signs of recent childbirth, 

171 
uterus, 169 
management of the, 171 
the child, 174 
bathing, 175 
clothing, 177 
deformities, 176 
dressing the cord, 175 
dressing the child, 176 
feeding, 176 
toilet of new-born, 174 
urination and defeca- 
tion, 177 



372 



INDEX. 



Puerperium, t lie, management of the 
mother, 171 
after-pains, 172 
catheterization, 173 
defecation, 173 
diet, 174 
lochia, 172 
nursing, 174 
urination, 173 
variations in secretion 

of milk, 174 
visits, professional, 171 
physiology of the, 168 

post-partnm chill, 168 
pulse and temperature, 168 
secretions and excretions, 
168 

Rachitic pelvis, 208 

Rheumatism during the puerpe- 

rium, 345 
Robert's pelvis, 211 
Rubeola during the puerperium, 344 
Rupture of the uterus during labor, 
316 
diagnosis, 315 
frequency, 316 
etiology, 316 
mechanism of, 316 
prognosis, 318 
symptoms, 317 
treatment, 319 

general directions for de- 
livery in, 319 
special directions for par- 
ticular forms of rupture, 

3'9 
varieties, 316 

complete, 316 
incomplete. 316 

Scarlatina during the puerperium, 

344 
Schultze method of artificial respira- 
tion, 350 



Septicaemia, puerperal, 325 

Sexual organs, 13 

Signs ot recent childbirth, 171 

Simple flat pelvis, 204 

Simpson forceps, 263. 269 

Skene, glands of, 19 

Skull of foetus at birth, 132 

Smellie forceps, 263 

Solid tumors of birth canal, 216 

Special lesions of puerperal fever, 

329 
Specific endometritis, 120 
Spermatozoa, 32 
Spondylolisthetic pelvis, 212 
Sprue in new-born child, 355 
Stages of labor, 127 

first or dilating, 127 
second or expulsive, 129 
mechanism of, 129 
rupture of bag of waters, 128 
third or placental, 130 

detachment of placenta, 130 
expulsion, 130 
retraction of uterus, 130 
Subinvolution, 342 
diagnosis, 343 
etiology, 343 
treatment, 343 
Substitute reeding, 178. 182 

practical hints for assimilation 
of, 187 
Sudden death during labor, 308 
Sutures of fetal head at birth, 132 
Symphyseotomy, 285 
Ayres' method, 288 
contraindications, 285 
indications, 285 
subcutaneous metho;!, 286 
technique of operation, 286 
varieties of incision, 286 
Syncytial cancer, 117 
Syphilis in new-born child, 356 
of placenta, 121 

Tedious labor, 193 



INDEX. 



373 



Tetanus in new-born child, 357 
Thrush in new-horn child, 355 
Toilet of new-born child, 174 
Transverse presentations, 238 
Traumatism of new-born infant, 352 

brain, 352 

caput succedaneum, 353 

cephalhematoma, 353 

fractures, 352 

nervous system, 352 
Tubes, Fallopian, 22 

anatomy of, 22 
Tumors of pelvic interior, 213 

Umbilical cord, 39, 42 

diseases of, 122 

anomalies in situation, 122 
variations in length, 122 
treatment, 122 

irregularities of, 254, 256 

ligation of, 162 

structure of, 42 
Umbilical vesicle, 35 
Umbilicus, diseases of, 357 
Urethra, 18 

composition of, 18 

glands of, 19 
Urination after labor, 173 

and defecation in new-born in- 
fant, 177 
Urine during the puerperium, 346 
Uterine apathy or inertia, 194 
Uterus, 19 

after labor, 169 

anatomy of, 20, 21 

ligaments of, 22 

nerves of, 22 



Uterus, puerperal, inversion of, 320 
rupture of, during labor, 316 
vessels of, 22 

Vagina, 18 

changes in, after labor, 170 

composition of, 18 

extension of, 18 

lacerations of, during labor, 311 

nerve supply, iS 

vascular supply, 18 
Variola during the puerperium, 344 
Version, 275 

bipolar, 277 

combined, 277 

contraindications, 275 

external method, 276 

favorable conditions, 276 

Hicks' method, 277 

indications, 275 

internal, 278 

podalic, 278 

version by posture, 276 
Vesicular mole, 116 
Vessels of external sexual organs, 
16 

of uterus, 22 
Vestibule, 15 
Vitelline duct, 35 

membrane of ovum, 31 
Vulvo-vaginal glands, 15 

WET-nursing, 181 
Whey, how to make, 184 

Yolk of ovum, 31 

Zona radiata of ovum, 31 



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A TREATISE ON NASAL SUPPURATION ; OR, SUPPURATIVE 
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12 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 



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Keyes, Edward L., A.M., M.D., 

and 

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14 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 



Manson, Patrick. 

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McQillicuddy, T. J., A.n., n.D. 

FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM IN 
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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 15 

Montenegro, Dr. Jose Verdes, 

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BUBONIC PLAGUE. Its Course and Symptoms and Means of Preven- 
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16 PUBLICATIONS OF WILLIAM WOOD & COMPANY. 



Noyes, Henry D., H.D., 

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